Not enough there, too many here: understanding geographical imbalances in the distribution of the health workforce

Background  

Efforts to increase access to life-saving treatment, including antiretroviral therapy (ART), for people living with HIV/AIDS in resource-limited settings has been the growing focus of international efforts. One of the greatest challenges to scaling up will be the limited supply of adequately trained human resources for health, including doctors, nurses, pharmacists and other skilled providers. As national treatment programmes are planned, better estimates of human resource needs and improved approaches to assessing the impact of different staffing models are critically needed. However there have been few systematic assessments of staffing patterns in existing programmes or of the estimates being used in planning larger programmes.     

For public service or money: understanding geographical imbalances in the health workforce

Geographical imbalances in the health workforce have been a consistent feature of nearly all health systems, and especially in developing countries. In this paper we investigate the willingness to work in a rural area among final year nursing and medical students in Ethiopia. Analysing data obtained from contingent valuation questions for final year students from three medical schools and eight nursing schools, we find that there is substantial heterogeneity in the willingness to serve in rural areas. Using both ordinary least squares and maximum likelihood regression analysis, we find that household consumption and the student's motivation to help the poor are the main determinants of willingness to work in a rural area. We carry out a simulation on how much it would cost to get a target proportion of health workers to take up a rural post.     

Priority setting in health care systems: too much or not enough

Introduction  

Various forms of the managed-care concept have been conceived to reconcile the medical professionalism with necessary cost-cutting measures in health-care provision. A plethora of bureaucratic regulations and required paperwork result in increasing resignation among physicians and withdrawal from patient care.     

National health insurance in the United States: a drama in too many acts

Responding to the question, "Universal Health Care: How Can We Get There from Here?," this paper describes the history of governmental health insurance in the United States, analyzes the factors that have proved to be crucial to its establishment in other countries, and concludes that without a strong Labor Party, there will be no national health insurance, no universal healthcare system in the United States.     

Quality here,there and everywhere: the application of a multi-dimensional learning tool to learning disability health services

The following paper examines the applicability of Maxwell's Multi-dimensional Quality Evaluation model to community learning disability health services. The model defines seven dimensions against which the quality of any given service can be measured: effectiveness, efficiency, economy, equity, access to services, appropriateness and social acceptability. A number of examples in relation to community learning disability services are discussed.     

The health workforce crisis in Bangladesh: shortage, inappropriate skill-mix and inequitable distribution

Background  

Bangladesh is identified as one of the countries with severe health worker shortages. However, there is a lack of comprehensive data on human resources for health (HRH) in the formal and informal sectors in Bangladesh. This data is essential for developing an HRH policy and plan to meet the changing health needs of the population. This paper attempts to fill in this knowledge gap by using data from a nationally representative sample survey conducted in 2007.     

‘Not too much, not too little, but just enough?’: observations on continuing professional development in Public Health in the North of England

Three inquiries about Public Health continuing professional development were undertaken in the Northern and Yorkshire Region of the National Health Service during 1995–96. Public Health Physicians were asked about their experience of continuing education and for their views on a regional policy for continuing professional development. Health Authority Chief Executives were asked about their reactions to Public Health Physicians continuing educational needs.The overall response rates for the Public Health Physicians were very disappointing. Most of the Chief Executives (a much smaller group) responded to the inquiry. A large minority of Public Health Physicians believed that their continuing education in the preceding two years had been adequate. Most wished their future continuing education activities to be multi-disciplinary. One finding with considerable significance for those managing Public Health education, both specialist and continuing, was that many of those with teaching responsibilities had not been trained to teach. Despite apparent concordance between the views of Chief Executives and those of Public Health Physicians; on some important points there were inconsistencies in the comments of Chief Executives, which suggested lack of understanding of both the roles of their professional colleagues and the need for their continuing education. The inquiries gave rise to a sense of apathy and under-confidence, manifested in some reluctance to accept policing of continuing education. There is a need to experiment with learning and teaching approaches in order to progress from the current traditional educational methods.Although there are signs of promise for the future, much more is still needed.     

Being there is important, but getting there matters too: the role of path in the valuation process.

PURPOSE: Traditional decision-analytic models presume that utilities are invariant to context. The influence of 2 types of context on patients' utility assessments was examined here the path by which one reaches a health state and personal experience with a health state. METHODS: Three groups of patients were interviewed: men older than age 49 years with prostate cancer but no diabetes (CaP), diabetes but no prostate cancer (DM), and neither disease (ND). The utility of erectile dysfunction (ED) was assessed using a standard gamble (SG). Each subject completed 2 SGs: 1) a no-context version that gave no explanation for the cause of ED and 2) a contextualized version in which prostate cancer treatment, the failure to manage diabetes, or the natural course of aging was said to be the cause. RESULTS: Patients with disease assigned higher utilities to ED in a matching context than in discrepant contexts. Regression models found that the valuation process was also sensitive to the match between disease path in the utility assessment and patients' personal experiences. CONCLUSIONS: These findings lend insight into why acontextual utility assessments typically used in decision analyses have not been able to predict patient behavior as well as expected. The valuation process appears to change systematically when context is specified, suggesting that unspecified contexts rather than random error may lead to fluctuations in the values assigned to identical health states.     

The future of community-centred health services in Australia: 'When too many beds are not enough'

The authors welcome a constructive debate on the future of community-centred health services. Therefore, we have written this piece in response to an article published by Cunningham in the previous edition of the Australian Health Review (Cunningham, Australian Health Review 2012; 36: 121-124), which was a very limited analysis and misleading critique of our previous contribution to this journal (Rosen et al. Australian Health Review 2010; 34: 106-115). The focus here is necessarily brief and does not stand in for a detailed analysis of the evidence base. The aim instead, is to draw attention back to the broader political economic and social dimensions of how the retreat from community health services has affected clinical care. We also outline a response to a longstanding assumption, or belief, that too many hospital beds are not enough and may never be enough. How we understand the problem of resource allocation in healthcare shapes the remedies that are considered realistic. We explain that the reasons for the systematic underdevelopment of community health services are complex, historical, and largely relate to political and economic factors, but they are still amenable to change.     

Uses of population census data for monitoring geographical imbalance in the health workforce: snapshots from three developing countries

Background  

Imbalance in the distribution of human resources for health (HRH), eventually leading to inequities in health services delivery and population health outcomes, is an issue of social and political concern in many countries. However, the empirical evidence to support decision-making is often fragmented, and many standard data sources that can potentially produce statistics relevant to the issue remain underused, especially in developing countries. This study investigated the uses of demographic census data for monitoring geographical imbalance in the health workforce for three developing countries, as a basis for formulation of evidence-based health policy options.     

Geographic distribution of the Australian primary health workforce in 1996 and 2001

OBJECTIVE: To analyse the geographic distribution of medical and non-medical primary health professions in 2001, and to compare this with 1996. DESIGN AND SETTING: Census data on the number and characteristics of selected health professionals in Australia by remoteness areas (as measured by the Accessibility Remoteness Index of Australia) were obtained from the Australian Bureau of Statistics. MAIN OUTCOME MEASURES: Number of general medical practitioners, allied health professionals and nurses per capita in Australia by remoteness areas in 2001 and 1996. RESULTS: In 2001, the number of general medical practitioners per capita in major cities was significantly higher than the numbers in inner regional areas, outer regional areas, and remote areas. This was also true of the number of allied health professionals per capita. The number of nurses per capita did not show the same pattern. From 1996 to 2001, the number of general medical practitioners per capita showed the largest increase in outer regional areas (10%) and no change in remote areas. The allied health professional workforce per capita increased significantly in all regions, while the nursing workforce per capita showed no significant increases. CONCLUSIONS AND IMPLICATIONS: Supply of all primary health professionals in remote areas remains low, and distribution patterns changed little from 1996 to 2001. The implementation of numerous government health workforce initiatives has coincided with little observable change in geographic distribution of the health workforce up to 2001.     

Not too little,not too much: supervisor perceptions of work-readiness of speech-language pathology graduates

Advances in Health Sciences Education - The work-readiness skills and attributes that facilitate healthcare graduates to succeed in their new workplaces are not well defined. In particular, the...     

'Not living life in too much of an excess': lay men understanding health and well-being

While research on lay perspectives of health now has a well established history, specific empirical data on male lay perspectives of health and well-being are largely absent. Drawing on focus group data and in-depth interviews with 20 lay men (including sub-samples of gay men and disabled men), and seven health professionals, this article explores how the men conceptualized 'health' and the gendered nature of such conceptualizations. Specific emphasis is given to considering notions of 'control' and 'release', and the associated issues of 'risk' and 'responsibility', in the participants' health narratives. A conceptual model for understanding 'masculinity' and 'health' is presented.     

A cost-minimization approach to planning the geographical distribution of health facilities

This paper illustrates a method of planning the geographic distribution of health facilities in order to maximize the social benefits achievable from the investment. Data from Bangladesh have been used to determine the optimal distribution of emergency obstetric care (EOC) facilities in the country using the estimates of average social cost per woman. Costs incurred by households, including the costs associated with maternal mortality, tend to increase with increasing radius of a facility's catchment area. The average facility-based costs tend to decline with increasing radius due to lower per capita capital expenditures. The summation of these two average cost functions generates a U-shaped curve. In this research, the minimum point of the aggregated average cost curve defines the 'optimal' radius of a health facility. The catchment area defined by the optimal radius minimizes the average social cost of providing EOC services in a region. The empirical analysis suggests that the optimal radius for the 20 regions of Bangladesh varies from about 6 to 12 km. If the optimal radius of the catchment area is used in planning health centre locations, Bangladesh will need to set up 450 EOC facilities; currently there are only 90 such facilities.     

The power of the soul. Business expertise is not enough; executives in Catholic health care must be spiritual leaders,too

After more than 20 years in health care, including at least a decade in leadership, this day was perhaps my darkest on the job. Since becoming chief operating officer of this Catholic hospital, I, with the help of my management team, had struggled to find answers to apparently overwhelming financial and operational challenges. I had been forced to make tough decisions in the pursuit of financial stability. In round-the-clock meetings, my team and I (with the assistance of a consulting firm whose specialty was turnarounds) had dissected every aspect of the operation. I had compared the performance of the hospital to industry benchmarks, never wanting to be unfair in expecting more from my staff than others had accomplished. In fact, in every decision I made I tried to be fair, weighing the different interests at stake before choosing a course of action--all the while knowing that, no matter what, I would make someone angry. Those around me, instead of recognizing my efforts to be fair, seemed to feel they had been betrayed. The whole organization was dispirited. My medical staff support was eroding as physicians refocused their practices at other facilities not faced with the challenges I had to address. Local leaders roundly criticized me for what they saw as abandoning the community's needs in the interest of serving the hospital and its bottom line. Then came the most hurtful news of all. My employees had filed a petition for representation by a union. It was not that I had a problem with organized labor. But how could an organization that I led have come to a place where the staff felt so abandoned by my leadership that they needed someone else to represent and protect their interest? Hadn't I tried hard to educate the staff about the changes in health care reimbursement? Hadn't I told them that the very existence of the hospital was at stake? Didn't they see how hard I worked, how much I cared? What was I to do now?     

Time-capsule thinking: the health care workforce,past and future

The size and shape of the U.S. health care workforce are in constant evolution. Using the metaphorical device of a time capsule, this essay examines the past and future of the workforce. It traces the growth, specialization, and diversification of health care workers during the twentieth century, emphasizing the particular expansion of the nonmedical aspects of the workforce. Looking ahead, the paper examines technology, informatics, nursing, provider distribution, and the global migration of health care workers as pivotal issues for the future of the workforce.     

公共卫生医师定位的思考

国家治理现代化进程中实现“健康中国”有赖于健全的公共卫生体系,其关键在于一支技术过硬、数量充足、能适应时代需要的公共卫生医师队伍。然而我国各界对于公共卫生医师的认知很少,公共卫生医师队伍目前存在着严重的身份危机问题。公共卫生医师的身份危机主要表现在两个方面。一是公共卫生医师的“医师”身份缺失的危机,二是公共卫生医师的功能角色模糊,存在可替代性的危机。建议应首先明确我国公共卫生医师是否为预防医学医师,重新定位设计“公共卫生医师”的角色,将预防医学本科学历作为公共卫生医师准入的基本条件,适度拓宽临床医学专业医学生考取公共卫生医师的途径,改革预防医学与公共卫生教育培养体系。