Overcoming Human-Resources- for-Health Challenges at the Service Delivery Level
Stephen N. Kinoti and Nigel Livesley
Health Care Improvement Project, University Research Co. LLC, United States
A comprehensive response to human-resources-for-health (HRH) challenges requires both macro- and micro-level interventions. Macro-level interventions are well suited for international- and national-level action. At the service delivery level, however, institutional and micro-level interventions are required to attract, train, and retain health workers in sufficient numbers. These workers must then be equitably deployed and consistently motivated to provide high-quality services. The second High-Level Forum on Health Millennium Development Goals (MDGs), held in Abuja, Nigeria, in December 2004, acknowledged that unless action is urgently taken to address the HRH crisis, many countries will fail to reach the MDGs. It was acknowledged at that time that this failure would represent not merely a missed deadline but a real calamity for the impoverished citizens of the affected countries.1
The HRH crisis is being experienced by fragile health-care systems in many developing countries and is the result of several macroeconomic factors as well as poor governance. This crisis, while long-standing, is compounded by the magnitude of the HIV pandemic, which has led to excessive workloads and burnout, high worker attrition rates, and limited entry of young professionals into the workforce. Any solutions to this crisis must therefore address broader macroeconomic factors as well as the local conditions influencing the availability of human resources on the ground. The World Health Organization (WHO) 2006 World Health Report2 included global, regional, and country-level profiles of workers in the health sector and provided new data on health worker demographics. It also provided recommendations for the future development of HRH from the WHO-led task-shifting consortium.3
According to the Global Health Workforce Alliance, in 2006, sub-Saharan Africa, home to about 11% of the world’s population, bore more than 24% of the global disease burden; yet it was home to just 3% of the global health workforce and spent less than 1% of the world’s financial resources on health. In most developing countries, the health workforce is concentrated in major towns and cities, while rural areas, on average, contain only 23% of the country’s doctors and 38% of its nurses.4 Imbalances exist not only in the total numbers and geographical distribution of health workers, but also in the skills mix of available health workers. WHO estimates that 57 countries worldwide (36 of which are in sub-Saharan Africa) have such a critical shortage of health workers that the countries would need to increase their health workforce by about 140% to achieve enough coverage for essential health interventions in order to make a positive difference in the health and life expectancy of their populations.5
Reasons for the Human Resources Crisis
The major challenges to building an effective health-care workforce in developing countries include
- low absolute numbers of trained health workers;
- difficulties in recruiting, retaining, and managing health workers;
- the impact of HIV on the health workforce; and
- poor health-worker performance.
Low Absolute Numbers of Trained Health Workers
In many developing countries, the capacity for training health workers is limited. For example, Ethiopia, with a population of 75 million, trains about 200 doctors a year, whereas the United Kingdom, with a population of 60 million, trains more than 6,000 doctors a year.6 Two-thirds of the countries in sub-Saharan Africa have only one medical school, and some countries have none.7 In addition to the low capacity for training, there is a growing sense that in sub-Saharan Africa, the medical profession—and the clinical disciplines in particular—have become less attractive to new entrants due to low salaries in the public sector, low morale among existing health-service providers, dilapidated health systems, and fear of HIV infection. These factors need to be researched further to understand the role they play in attracting and retaining a high-quality health-care workforce.
Difficulties with Recruitment and Retention
Many facilities face difficulties in recruiting and retaining health staff. An important reason for this challenge is that health workers often migrate to find better opportunities. This migration includes international migration, internal rural-to-urban migration, migration from clinical to administrative jobs, migration from the public to the private or nongovernmental organization (NGO) sectors, or migration out of the health-care sector entirely.
Both push and pull factors are associated with migration. Push factors are those negative factors that lead to dissatisfaction with where the health worker currently works. Low wages, lack of additional training opportunities, poor working and living conditions, and lack of social and retirement benefits are commonly cited push factors.8 Pull factors are those factors that make other potential jobs or areas more attractive, including higher salaries, better working conditions, better benefit packages, training opportunities, and recognition of good performance.9
In a 2004 analysis of staff loss rates in Zambia, Huddart et al10 showed an annual rate of loss of 20% for clinical officers and 36% for midwives, with loss rates for doctors and nurses falling somewhere in between. In Malawi, death and resignation were the main causes of health-care worker attrition (Figure 1).11 Deaths often result in posts being left vacant because no additional staff are available to replace those who have passed away.
Impact of HIV Infection on the Health Workforce
In the study by Gonani et al,11 death contributed 48% of health-worker attrition—with 73% of these deaths attributed to HIV—making HIV a significant threat to HRH. The Joint Learning Initiative has identified three ways in which HIV poses a great threat to the health workforce.12 First, HIV is associated with increased workloads and skill demands; second, health workers frequently fall ill and die from HIV infection; and third, health workers must cope with the psychosocial stress of caring for increasing numbers of dying patients, in addition to caring for their own sick family members.12 In addition, fear, stigma, and discrimination affect worker motivation and performance.
Figure 1. Causes of attrition among health workers in six selected districts, Malawi, 1996–2002 (n=527)
Source: Gonani et al.11
A major concern among clinical service providers and other support staff in developing countries is the risk of contracting an infection such as HIV in the course of performing their regular duties. In studies conducted in Kenya13 and Malawi,11 9 out of 10 health managers perceived the risk of HIV infection to be high or very high. Reasons for this perception included lack of skills in infection prevention, delays in investigation of patients (e.g., those with signs or symptoms of TB), and lack of protective materials due to stock-outs and staff negligence. These fears led providers to avoid performing certain tasks or to leave clinical service altogether.
A study in South Africa found that 11.5% of health workers in two public hospitals were HIV positive. The proportions were highest among nurses, student nurses, and younger staff. Of those living with HIV, 19% had CD4 counts below 200 cells/mm3 and were therefore eligible to receive antiretroviral therapy (ART).14 In addition to directly affecting the lives of health workers, the HIV epidemic has led to widespread fear of infection, increased workload, and burnout.15 Research in Swaziland has suggested that these factors can lead to significant decreases in the quality of health-care services.16
There is also fear that the rapid scale-up of ART, because it is so labor intensive, will negatively affect other non-HIV-related health programs. However, early evidence suggests that the num ber of health worker lives saved by ART may offset the additional human resources needed to implement HIV treatment programs.17
Poor Health Worker Performance
In addition to problems created by the lack of absolute numbers and the inequitable distribution of health workers, there is also the problem that health workers do not always provide an acceptable level of care. In a 2005 review of this issue published in The Lancet,18 it was found that determinants of health workers’ performance included their knowledge, skills, motivation, and experience, and attitudes toward their job, workplace, and patients. The review also listed nonhealth-worker factors, such as the quality of the guidelines workers are expected to follow and the health facility environment (e.g., workload, availability of equipment, attitudes of co-workers and supervisors, and the degree of control workers have over the work environment), as well as external factors, such as the socioeconomic and political environments of the country or region in which the workers are practicing.
A study by Manongi et al19 explored the experiences of health workers in the primary health-care facilities of the Kilimanjaro region of Tanzania. The study looked at workers’ motivation, satisfaction, and frustration and attempted to identify areas in which sustainable improvements to services could be achieved. It was discovered that the primary factors influencing worker motivation were the complexities of multitasking in the context of staff shortages, a desire for more structured and supportive supervision from managers, and improved transparency in career development opportunities.
Strategies to Address HRH Challenges
Increase the Number of Trained Health Workers
Efforts to train existing health workers in developing countries are growing as wealthier nations increase aid to these countries and recognize the futility of providing lifesaving medicines in the absence of properly educated medical personnel. National governments of developing countries are also beginning to increase investments in training more health workers, but these investments have so far fallen short of what is needed.
Some innovative approaches to increasing the number of trained health workers and for developing training programs to address some of the maldistribution problems have been attempted in various countries. For example, some countries offer free medical training to students from developing countries. Cuba graduated nearly 4,000 international students from its medical schools between 1966 and 2004.20 Medical schools within developing countries have also been founded or expanded using funds from international donors, including governments, nongovernmental development agencies, or medical schools in wealthier countries.21 Increasing the number of medical trainees will not necessarily solve all aspects of the workforce crisis. Egypt, for example, trains more physicians than it needs, but because of the low remuneration for working in rural areas, doctors often prefer to leave the country or leave the profession rather than move to rural areas.22
Recruitment and Retention
Decrease the Barriers to Hiring New Staff
The Capacity Project, an initiative supported by the United States Agency for International Development (USAID), has worked with health sector leaders to develop the Emergency Hiring Plan (EHP), a rapid-response staffing and training model designed to increase the number of qualified health professionals available to work in public health facilities.23 The EHP is helping the Kenyan Ministry of Health expand access to treatment and care through rapid hiring, training, and deployment of 830 health workers. This aid has shortened the recruitment process from more than a year to three and a half months. The new hires are given three-year contracts; afterward, the Ministry of Health absorbs them into the regular workforce. EHP hires also receive a two-week training session prior to starting work to update their HIV-related clinical skills. Once these workers are absorbed into the permanent service of the Ministry of Health, they receive routine in-service training alongside other regular staff.
Reduce International Migration
According to a 2004 report by the Africa Working Group of the Joint Learning Initiative on Human Resources, brain drain of health professionals due to international migration has reached serious proportions and is likely to be the single most important source of attrition from the health workforce in many countries in the region.24 A variety of meetings and consultations have led to policy declarations and proposals for action, in an effort to create an environment for effectively tackling human resource issues backed by strong political will. In 2002, the African Union, at its meeting in Durban, South Africa, declared 2004 a Year of Human Resources Development, with special emphasis on health.25 The establishment of the New Partnership for African Development (NEPAD) has also created avenues for multicountry efforts to tackle the health crisis in Africa. Several NEPAD deliberations have focused on strengthening human resources, with an emphasis on health. In addition, several initiatives have been started in conjunction with various international partners. Among these initiatives are the development of a NEPAD health strategy and an initial plan of action, which includes a proposal to “reach an international agreement on migration especially with regard to ethical recruitment of health personnel from Africa, whilst putting in place mechanisms to address the adverse conditions of service for health professionals.”26
Reduce Internal Migration at the Local Level
Whereas most workers identify salary level as an important push or pull factor, it is not the only factor in worker retention. Good accommodations, the quality of health-care facilities, and the welfare of the worker’s entire family are all important in the professional development of health workers. Attention to these factors has been shown to improve retention in high-income countries.27,28,29
Decrease Rural/Urban Health-Care Inequities
The unequal distribution of health staff is a significant challenge for rural facilities. For example, in Nairobi, Kenya, there is one doctor per 500 people, whereas the remote Turkana district of Kenya has one doctor per 160,000 people.30 Countries have used a variety of strategies to reduce geographical disparities, including increasing training opportunities for students from rural areas, providing a rural experience during pre- or postgraduate training, increasing the number of nonspecialist trained staff, and providing financial and nonfinancial incentives for health workers in rural areas.
A common strategy for increasing the number of health workers in rural areas is to provide training for students who come from rural areas. A wealth of evidence from developed countries indicates that students from rural areas are more likely to practice their profession in rural areas.31,32 This finding also holds true in South Africa33 and Thailand,34 where medical students from rural areas are more likely to return to those areas after graduation. Even if students do not originate from rural areas, providing rural experiences during pre- or postgraduate training can increase the chances of their practicing in rural areas. Again, although much of these data are from developed countries,35 evidence also exists from Ghana and Thailand34,36 that providing rural training experiences will increase the chance of trainees accepting a rural position. Another strategy is to increase the number of general physicians trained. Brazil and Canada have attempted this strategy based on the assumption that generalists are more likely to move to rural areas.37
In addition to making changes in the education of medical professionals, governments have provided incentives to recruit and retain staff in rural areas. South Africa, for instance, has introduced an 8% to 22% salary bonus for staff working in rural areas, depending on the cadre of staff and the rural designation of the placement. A survey conducted soon after this program was implemented found that 28% to 35% of staff in rural areas had decided to stay for the next year because of the rural allowance.38 According to another South African study, rural doctors stated that higher salaries would have the most effect on retention in rural areas but that nonfinancial incentives were also important. The three most important nonfinancial factors identified in this study were suitable accommodation, a good hospital environment and working conditions, and increased career opportunities. At least one of the doctors interviewed also listed access to continuing medical education, recognition and appreciation, and good staff relationships as important factors in retention.39
Decrease Staff Turnover
Most of the data on reducing staff turnover come from fields outside of health care or from health-care systems in high-income countries. In the following sections, we will review the general principles from these fields and then discuss examples of how these principles have been practiced in developing countries.
Husselid40 examined the association between human resource (HR) management practices of 968 American companies in various fields and their turnover rates, productivity, and financial performance. He grouped HR management considerations into two categories: (1) employee skills and organizational structures and (2) employee motivation (see Box 1).
The average annual turnover across all the companies in Husselid’s study was 18%.40 Companies that received higher ratings for employee skills and organizational structures had lower turnover rates. The factors relating to employee motivation were not associated with turnover. The author felt that although paying attention to motivation would help decrease turnover, performance appraisal and linking compensation to performance could increase turnover by causing weak staff members to leave. The same study found that staff productivity and company financial performance are both positively associated with good employee skills, good organizational structures, and employee motivation.
Within the health-care field in developed countries, a number of studies have examined the characteristics of hospitals with low turnover rates and the reasons staff members choose to leave a given facility. The NEXT Study Group compared the opinions of 1,175 nurses from hospitals with low and high turnover rates.29 Nurses from the low-turnover hospitals perceived fewer job opportunities in their local area, but they also expressed more positive feelings about the hospital where they worked. For instance, those nurses had a shorter commute, recognized lower exposure to hazards in the workplace, had more control over their work schedule, were happier with their roles and the latitude to make decisions in their jobs, and had a better effort-reward ratio. They also recognized better relationships with management and other health-care staff and received more professional development.
Similar factors are associated with staff turnover and retention in developing countries. In Uganda, one study found that intention to stay was positively correlated with workers being actively involved in the facility, having a manageable workload, having flexibility to balance the demands of work and personal life, and having opportunities for promotion.41 The study also found that worker satisfaction (a predictor of turnover) was associated with the worker feeling that the job was a good match, being satisfied with the salary, being satisfied with the supervisor, having job security, and perceiving the job as stimulating or fun.
According to a review of literature on the use of nonfinancial incentives for health worker retention in 16 countries in eastern and southern Africa (Angola, Botswana, Republic of Congo, Kenya, Lesotho, Madagascar, Malawi, Mauritius, Mozambique, Namibia, South Africa, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe), health workers receive a variety of nonfinancial incentives, including training and career path incentives, housing, transportation, child care, improvements to facilities, and security.42 Of the 16 countries assessed, 15 had also developed HR information systems.
Reduce the Effects of HIV
The first step in reducing the direct effects of HIV, as well as the stress related to the fear of infection, should be the introduction of good infection control procedures to protect health workers from nosocomial HIV infections.43 The use of postexposure prophylaxis to be taken in the event of a needle stick can also increase worker safety; however, staff members often do not report needle sticks due to reluctance to be tested for HIV, a prerequisite for receiving prophylaxis.44 It is also important that workers living with HIV have access to treatment. Although there are various models for this, they all need to be confidential, conveniently located, and easy for staff members to access.45
Improve Performance of Existing Staff
Even when absolute numbers of staff are low, there is an evidence base regarding how to improve the productivity and performance of existing staff. The main strategies for doing so include training, supervision, performance appraisal, changes to the way in which services are delivered, and implementation of modern quality-improvement methodologies.
Training
In March 2008, the Global Health Workforce Alliance First Forum of Human Resources for Health was held in Kampala, Uganda,46 with the theme of “Health Workers for All and All for Health Workers: An Agenda for Global Action.” Participants drafted the Kampala Declaration, which recognizes a shared vision in which “all people, everywhere, shall have access to a skilled, motivated and facilitated health worker within a robust health system.” An important ingredient of this commitment is the need for scaling up health worker education and training, not only in terms of technical skills but also in sustainable, continuous quality improvement and capacities.
Supervision beyond Checklists
Although in the past traditional supervision has yielded some improvements in health worker performance, recent work by organizations involved in quality improvement has demonstrated that it is necessary to go beyond traditional models to incorporate organizational and individual staff management and support approaches that lead to higher levels of performance and improved outcomes. For example, in a study to gather examples of how different service delivery organizations in Guatemala try to manage and improve the performance of their staff, it was found that availability of resources is a key factor in influencing staff performance.47 Providing resources to carry out fieldwork and offering salaries that are competitive within the national labor market appeared to have the greatest influence on staff performance. Additional important influences for ensuring improved performance included supervision linked to support for the performance of clearly defined individual tasks, coaching and mentoring, measuring, and monitoring.
Quality Improvement Methods
Over the years, the Quality Assurance Project (QAP)—the predecessor of the Health Care Improvement Project implemented by University Research Co. LLC—has been involved in using quality improvement methods to help provider teams identify barriers to providing effective and efficient health care and to develop solutions to these problems.48 This approach has led to more motivated staff, improved service delivery systems, and improved care outcomes. Examples of programs that have utilized this approach with subsequent improvements in staff performance and outcomes are presented on the QAP Web site (http://www.qaproject.org). Some of the improvements achieved by these programs include decreased postpartum hemorrhage, improved compliance with standards of care, improved adherence to antiretroviral (ARV) medicines, better triaging of children with serious illnesses, and better outcomes of emergency care, such as reduced deaths within 24 hours of admission. Importantly, these improvements have been made by changing the process of care delivery and without increasing the number of health-care workers.
Changes in Health Care Service Delivery
Highly skilled doctors are not available in large enough numbers to provide services to the majority of clients, especially in rural areas. One solution to address this is task shifting to well-trained lower-level cadres of service providers—for example, clinical officers and nurses instead of doctors.Different countries have a variety of locally trained indigenous health professionals—clinical officers in Malawi and Zambia, surgical and medical technicians in Mozambique, assistant medical officers with surgical and obstetric skills in Tanzania, and medical assistants in Ghana. The medical licentiates and clinical officers in Tanzania are trained to diagnose, treat, and prescribe and can therefore fulfill many functions in district hospitals that the shortage of doctors would otherwise have made impossible. Likewise, nurse practitioners in Swaziland and enrolled nurses in Malawi have played immense roles in their health systems, particularly in remote areas where it is difficult to get better-qualified health professionals to practice. These cadres typically require two to three years of postsecondary training, rather than the five to six years required for medical doctors.
Data show that tasks previously performed by doctors can be performed equally well by both nonphysician clinicians50 and nurses. Other data support the use of lay health workers to effectively deliver malaria treatment,51 increase immunization uptake, and improve treatment of TB.52 Mounting evidence also indicates that nonphysician practitioners (primarily clinical officers and nurses) can, with adequate training, deliver ART to HIV-positive patients.53
A few studies have documented the effectiveness of using nonphysician providers and lay health workers to increase capacity for HIV-related services. In 2003, a study conducted at 16 health-care sites in Zambia offering various HIV-related services (e.g., voluntary counseling and testing, prevention of mother-to-child transmission, and ART) demonstrated that it is possible to improve performance through the use of trained laypersons.54
Task Shifting Guidelines in the Era of HIV Program Expansion
Francesca Celletti,a Badara Samb,a Anna Francesca Wright,b Alan Greenberg,c and Joan Hollowayd
aWorld Health Organization, Switzerland
bIndependent Consultant, United Kingdom
cThe George Washington University School of Public Health and Health Services, Department of Epidemiology and Biostatistics, United States
dOffice of the U.S. Global AIDS Coordinator, President’s Emergency Plan for AIDS Relief, United States
One of the key constraints to the expansion of HIV services in resource-limited settings is a serious shortage of human resources for health. The shortage of well-trained health workers is global, but resource-constrained countries, particularly those in Africa, feel the crisis most acutely (see Figure 1). Put simply: there are not enough health workers to deliver on the target of universal access to HIV services.
The health workforce crisis is multifaceted and demands a comprehensive response that is aligned with broader health systems strengthening, including strategies to protect the health of the workforce and to treat those who are sick, to retain health workers in their jobs, and to train new and greater numbers of qualified professionals.1,2
There is also a need to seek innovative ways to make the best use of the available human resources for health and to quickly expand capacity. Many countries have responded pragmatically by adopting a task-shifting approach. This involves redistributing tasks rationally among health workforce teams so that specific tasks are moved, where appropriate, from highly qualified health workers to health workers with shorter training and fewer qualifications. Where further additional human resources are needed, task shifting may also involve the delegation of some clearly delineated tasks to newly created cadres of health workers who receive specific, competency-based training (see Figure 2). For example, in Malawi and Uganda, the basic care package for people living with HIV has been designed to be delivered by nonspecialist doctors or nurses, supported by community health workers and people living with HIV. Similarly, Ethiopia has implemented a plan to train and hire community health workers to expand the current workforce delivering HIV services. This can free up the bottlenecks in service delivery and support a rapid expansion in the availability of HIV services, especially at the community level.3
In January 2008, the World Health Organization (WHO) published a series of evidence-based recommendations and guidelines that represented the culmination of a broad-based process of consultation and evidence-gathering lasting more than two years.4 The WHO Global Recommendations and Guidelines on Task Shifting provide an authoritative framework that can help support and guide widespread implementation in countries that choose to adopt the approach as a national strategy for organizing the health workforce. This framework aims to bring clarity to the task-shifting experience and to identify and define the conditions and systems that must be in place if the approach is to prove safe, efficient, effective, equitable, and sustainable.
The recommendations and guidelines cover the need for consultation, situation analysis and national endorsement, and the need for an enabling regulatory framework. They specify the quality assurance mechanisms, including standardized training, supportive supervision, and certification and assessment, that will be important to ensure quality of care. The guidelines also cover the elements that will need to be considered for the purpose of ensuring adequate resources for implementation and offer advice on the organization of clinical care services under a task-shifting approach.
At the International Conference on Task Shifting in Addis Ababa, Ethiopia, the WHO Recommendations and Guidelines were endorsed in the Addis Ababa Declaration, which was unanimously adopted on January 10, 2008.5
Recent interest in task shifting has been accelerated by the need to urgently respond to the HIV pandemic with a rapid expansion of treatment and care. Task shifting, however, involves rationalizing and decentralizing the way in which all health services are delivered and embodies the core principles of public health services that are accessible, equitable and of good quality. As such, task shifting also offers long-term potential for all primary health-care services and for overall health systems strengthening.
Note: The WHO Global Recommendations and Guidelines on Task Shifting can be downloaded at http://www.who.int/healthsystems/task_shifting/en/.
Figure 1. The human resources crisis: health-care personnel (doctors and nurses) per 100,000 population
Source: World Health Organization. The World Health Report 2006: Working Together for Health. Available at: http://www.who.int/whr/2006/en/.
Note: PLHIV = people living with HIV
Figure 2. Task shifting: expanding the pool of human resources for health
Source: World Health Organization. Task Shifting Booklet (2007). Available at: http://www.who.int/healthsystems/task_shifting_booklet.pdf.
1. World Health Organization (WHO). Taking stock: health worker shortages and the response to AIDS. http://www.who.int/hiv/pub/advocacy/ttr/en/. Published 2006. Accessed June 2, 2008.
2. WHO. Treat, train, retain: the AIDS and health workforce plan. Report on the consultation on AIDS and human resources for health. http://www.who.int/hiv/pub/meetingreports/ttr/en/index.html. Published 2006. Accessed June 2, 2008.
3. Samb B, Celletti F, Holloway J, et al. Rapid expansion of the health workforce in response to the HIV epidemic. N Engl J Med. 2007;357(24):2510-2514.
4. WHO. Task shifting—global recommendations and guidelines. http://www.who.int/healthsystems/task_shifting/en/. Published 2007. Accessed June 2, 2008.
5. WHO. The Addis Ababa Declaration. http://www.who.int/healthsystems/task_shifting/Addis_Declaration_EN.pdf. Published January 2008. Accessed June 2, 2008.
In Mozambique, an intervention involving nurses performing CD4 lymphocyte counts, when implemented correctly, was associated with a more rational use of higher-level clinical providers, which may improve overall clinic flow and efficient use of the limited HR supply. However, this particular intervention did not lead to an increase in the number of patients starting ART or a reduction in the time to ART initiation. The length of time that the program had been operating played an important role in all outcomes, suggesting that general improvements in clinic efficiency may have overshadowed the effect of the intervention. The lack of observed effect in these outcomes may also be due to additional health system bottlenecks that delay the initiation of treatment in ART-eligible patients.55
More studies are needed to clarify the impact of changes to service delivery on the health workforce, particularly in light of increased global support for task shifting as a means to support the rapid scale-up of services. Although no one solution is available or feasible, the overall goal should be to get the right health workers with the right skills in the right place and doing the right things. Although each country is unique, each can and should learn from the experiences of others—best practices abound and need to be shared.
Conclusion
A major challenge to delivering quality services in developing countries is the growing shortage of trained health workers in countries already burdened with insufficient infrastructure, poor government health-care systems, and extreme poverty. Academic institutions lack the resources and faculty to produce enough qualified physicians. Doctors and nurses are leaving their home countries for better-paying jobs in developed countries or are migrating toward urban areas. Health-care professionals are also dying from the very infectious diseases they are needed to help prevent and treat. Overdependence on highly trained professionals, such as doctors, will thus limit the ability of these countries to scale up access to services.
Ultimately, in order to cope with these human resources challenges, it is essential to address both institutional and individual factors. Approaches at the institutional level include improved workforce management systems that pursue equitable distribution of health workers, staff inclusion in staffing-related decision making, clear job descriptions, improved communication between management and staff, supportive supervision, mentoring, and coaching. Approaches at the individual level include monetary and nonmonetary incentives, performance appraisal, career development, and task shifting linked to increased skills development. An effective response therefore requires a comprehensive approach that addresses institutional, facility, and individual factors in a holistic manner, while taking into consideration the needs and dynamics of the entire health-care system.
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