The crisis in human resources for health

Abstract

Strong worldwide commitment to meeting the 2015 targets for the Millennium Development Goals has led to a massive mobilisation of resources for global health, particularly HIV/AIDS. But big vertical initiatives, such as immunisation and large-scale treatment programmes, which tackle the major causes of ill health in developing countries, are now suffering not from lack of money but from the shortage of health workers to administer the programmes. Recognition that countries' abilities to solve this human-resource crisis will determine the future success of all vertical initiatives—and, in all likelihood, any attempts to improve health—is behind WHO's decision to highlight human resources in its 2006 World Health Report (WHR), which shares its theme with World Health Day on April 7. Years of underinvestment in health, coupled with enforced economic reforms that restricted investment in public health services and education, have left many countries with critical shortages of health workers. The attractions of international migration, and concentration of the remaining professionals in urban areas, means, according to the WHR, that many national health systems are weak, inequitable, unresponsive, and unsafe. This situation is made worse by changing epidemiological threats and the fact that the skills of available professionals are often not well matched to the local population's health needs. The central importance of human resources to health means this issue deserves high international priority. For this reason, the attention generated by the WHR, and its attendant political clout, is to be warmly welcomed. But the report is also a disappointment. In terms of providing the kind of detailed data on human-resource gaps and needs to help governments make resource decisions—the stated aim of the WHR—it falls far short. And, in fact, it goes little further than a substantial report published in 2004 by the Joint Learning Initiative (JLI)—an organisation of over 100 academics who attempted to quantify the scale of the problem and make the case for action. The WHR does proffer updated figures and estimates: WHO has revised down from 75 to 57 the number of countries with critical shortages of workers and has done new analyses of national censuses, labour surveys, and statistical sources to give a new total of full-time paid health workers of almost 60 million worldwide. But health workers are discussed as an artificially homogeneous group, with very little information about key attributes such as geographical distribution, types and level of skills, and the balance between public and private sectors. With the resources and manpower available to an international agency such as WHO—notably greater than those available to the small-scale JLI—it is difficult to understand why more has not been achieved in the past year and a half. Admittedly, part of the stagnation can be put down to logistics. Data collection is difficult because many health ministries, on which WHO relies for much of its information, have records of health workers in the public sector but an unreliable idea of the numbers of private or informal workers. What is more, assessment of ideal numbers of workers that ministries need to aim for does not take sufficient account of the epidemiological profiles of the countries, and relations between density of health workers and the full spectrum of health outcomes needs to be better researched. But these issues should be viewed as strong arguments for constructing a comprehensive and reliable framework to diagnose the detail of human-resource problems, rather than excuses for omission. Countries need to be able to precisely define their human-resource problems in order to design policies to address them. International agencies, too, need coherent investment strategies for real capacity building to take place. Both need to monitor success, by keeping track of numbers, skills, and geographical spread of health workers, and by matching these numbers with desired health outcomes and outputs. This information is crucial to the success of WHO's plans for immediate labour-market interventions to address the crisis, which focus on boosting education and ethical recruitment, enhancing performance through better management of workers, and managing migration and attrition. Given WHO's technical mandate, obtaining the data to support these activities should be at the centre of its efforts to address the crisis in human resources for health. But the patchy and incomplete picture presented in the WHR shows just how much of a gap exists between current knowledge and what is necessary to inform policymaking. Having recognised the importance of human resources to health, WHO must now ensure its own human resources can cope with the analytical burden of turning its workforce plans into action.