Working in health: financing and managing the public sector health workforce

Abstract

There are numerous voices calling for a “scaling-up of the health workforce” to enable low-income countries to accelerate progress towards achieving the health Millennium Development Goals. There are fewer voices asking about the fiscal and financial implications of “scaling-up”. This book will help policy-makers (and donors) to understand better the challenges raised by the “human resources crisis” described by the World Health Organization and others.1,2 The critical issues for those who control financial resources and are responsible for their allocation (which typically does not include ministries of health) are: how much is needed to hire more personnel, to pay more to existing personnel or to do both? Where will the money come from (taxpayers, other sectors, savings, external sources)? What will be the impact on other sectors of spending more on health? For instance, will paying health workers better have a spilling effect, and how much will that represent? Is more money really needed? It is not unusual for ministries of health not to fully spend their budget allocation, sometimes because they cannot find workers to employ, but most often because of bureaucratic bottlenecks (e.g. complex and lengthy recruitment, transfer, promotion processes). Better retention, including preventing emigration of qualified personnel, is a critical component of any scaling-up strategy. Why should more health workers be trained if it is only to see them migrate to greener pastures? All these questions are legitimate and advocates for scaling-up need to provide satisfactory answers. Ministries of health have to be able to show how much their proposals will cost, to demonstrate their capacity to actually spend more, to show that all efforts are being made to eliminate inefficiencies, and to convince funders that they have a strategy for using the strengthened health workforce in a way that makes services more accessible and more effective in improving the health of the population. These are some of the messages of this very useful book, which is structured to meet the expectations of policy-makers and academics alike. The first part spells out, very clearly indeed (which is not typical for this type of literature), the challenges of financing the health workforce. It derives lessons learned from four country case studies and proposes, in a non-prescriptive manner, policy options and their implications in terms of changes needed. The second part of the book presents case studies from the Dominican Republic, Kenya, Rwanda and Zambia. The reader will find here detailed descriptions and analyses of health workforce financing and management policies and practices; the approach used by the case writers is a useful methodological contribution. The last part, in the format of five appendices, gives the evidence that inspired the various policy options. Those on decentralization, on alternative modalities of compensation and on policies and practices (the two may differ) of the GAVI Alliance and the Global Fund to Fight AIDS, Tuberculosis and Malaria are of particular interest. The authors clearly explain why expansion of the health wage bill must not be done at the expense of other important expenditures in the health sector or in other sectors. It shows that the absence of budgetary autonomy of the ministries of health is a disincentive for them to develop strategies to mobilize and to allocate funds, and even to build adequate databases on their workforce, since control over available resources lies elsewhere. The case studies clearly show that there is room for improving the efficiency of the use of health workers. The problem is not a lack of policies but that they are not applied, for reasons ranging from low capacity to implement them (e.g. performance-based remuneration) to lack of monitoring mechanisms or simply the absence of political commitment. The authors recognize that the process of deciding how much the country will spend on health services and on paying health workers is essentially political. This is not to say that it is not rational; it is based on available information and on the perception that the money will be spent well. This book offers many strategies to health policy-makers to make a stronger case for additional funds to scale-up the workforce at their disposal. Its most important message is that the first step is to correct existing inefficiencies and to show that available resources are being used in an efficient manner.