Tackling health workforce challenges to universal health coverage: setting targets and measuring progress

Human resources for health (HRH) will have to be strengthened if universal health coverage (UHC) is to be achieved. Existing health workforce benchmarks focus exclusively on the density of physicians, nurses and midwives and were developed with the objective of attaining relatively high coverage of skilled birth attendance and other essential health services of relevance to the health Millennium Development Goals (MDGs). However, the attainment of UHC will depend not only on the availability of adequate numbers of health workers, but also on the distribution, quality and performance of the available health workforce. In addition, as noncommunicable diseases grow in relative importance, the inputs required from health workers are changing. New, broader health-workforce benchmarks – and a corresponding monitoring framework – therefore need to be developed and included in the agenda for UHC to catalyse attention and investment in this critical area of health systems. The new benchmarks need to reflect the more diverse composition of the health workforce and the participation of community health workers and mid-level health workers, and they must capture the multifaceted nature and complexities of HRH development, including equity in accessibility, sex composition and quality.     

Health workforce contributions to health system development: a platform for universal health coverage

Problem

In the 1970s, Thailand was a low-income country with poor health indicators and low health service coverage. The local health infrastructure was especially weak.

Approach

In the 1980s, measures were initiated to reduce geographical barriers to health service access, improve the health infrastructure at the district level, make essential medicines more widely available and develop a competent, committed health workforce willing to service rural areas. To ensure service accessibility, financial risk protection schemes were expanded.

Local setting

In Thailand, district hospitals were practically non-existent in the 1960s. Expansion of primary health care (PHC), especially in poor rural areas, was considered essential for attaining universal health coverage (UHC). Nationwide reforms led to important changes in a few decades.

Relevant changes

Over the past 30 years, the availability and distribution of health workers, as well as their skills and competencies, have greatly improved, along with national health indicators. Between 1980 and 2000 coverage with maternal and child health services increased substantially. By 2002, Thailand had attained UHC. Overall health system development, particularly an expanded health workforce, resulted in a functioning PHC system.

Lessons learnt

A competent, committed health workforce helped strengthen the PHC system at the district level. Keeping the policy focus on the development of human resources for health (HRH) for an extended period was essential, together with a holistic approach to the development of HRH, characterized by the integration of different kinds of HRH interventions and the linking of these interventions with broader efforts to strengthen other health system domains.     

Health financing for universal coverage and health system performance: concepts and implications for policy

Unless the concept is clearly understood, “universal coverage” (or universal health coverage, UHC) can be used to justify practically any health financing reform or scheme. This paper unpacks the definition of health financing for universal coverage as used in the World Health Organization’s World health report 2010 to show how UHC embodies specific health system goals and intermediate objectives and, broadly, how health financing reforms can influence these.All countries seek to improve equity in the use of health services, service quality and financial protection for their populations. Hence, the pursuit of UHC is relevant to every country. Health financing policy is an integral part of efforts to move towards UHC, but for health financing policy to be aligned with the pursuit of UHC, health system reforms need to be aimed explicitly at improving coverage and the intermediate objectives linked to it, namely, efficiency, equity in health resource distribution and transparency and accountability.The unit of analysis for goals and objectives must be the population and health system as a whole. What matters is not how a particular financing scheme affects its individual members, but rather, how it influences progress towards UHC at the population level. Concern only with specific schemes is incompatible with a universal coverage approach and may even undermine UHC, particularly in terms of equity. Conversely, if a scheme is fully oriented towards system-level goals and objectives, it can further progress towards UHC. Policy and policy analysis need to shift from the scheme to the system level.     

Implications of dual practice for universal health coverage

Making progress towards universal health coverage (UHC) requires that health workers are adequate in numbers, prepared for their jobs and motivated to perform. In establishing the best ways to develop the health workforce, relatively little attention has been paid to the trends and implications of dual practice – concurrent employment in public and private sectors. We review recent research on dual practice for its potential to guide staffing policies in relation to UHC. Many studies describe the characteristics and correlates of dual practice and speculate about impacts, but there is very little evidence that is directly relevant to policy-makers. No studies have evaluated the impact of policies on the characteristics of dual practice or implications for UHC. We address this lack and call for case studies of policy interventions on dual practice in different contexts. Such research requires investment in better data collection and greater determination on the part of researchers, research funding bodies and national research councils to overcome the difficulties of researching sensitive topics of health systems functions.     

Mapping the governance of human resources for health in Serbia

This article maps the current governance of human resources for health (HRH) in relation to universal health coverage in Serbia since the health sector reforms in 2003.The study adapts the Global Health Workforce Alliance/World Health Organization four-dimensional framework of HRH in the context of governance for universal health coverage. A set of proxies was established for the availability, accessibility, acceptability and quality of HRH. Analysis of official HRH documentation from relevant institutions and reports were used to construct a governance profile of HRH for Serbia from the introduction of the reform in 2003 up to 2013. The results show that all Serbian districts (except Sremski) surpass the availability threshold of 59.4 skilled midwives, nurses and physicians per 10,000 inhabitants. District accessibility of health workforce greatly differed from the national average with variances from +26% to −34%. Analysis of national averages and patient load of general practitioners showed variances among districts by ±21%, whilst hospital discharges per 100 inhabitants deviated between +52% and −45%. Pre-service and in-service education of health workforce is regulated and accredited. However, through its efforts to respond to population health needs Serbia lacks a single coordinating entity to take overall responsibility for effective and coordinated HRH planning, management and development within the broader landscape of health strategy development.     

Social health insurance in Nepal: A health system departure toward the universal health coverage

The World Health Organization has identified universal health coverage (UHC) as a key approach in reducing equity gaps in a country, and the social health insurance (SHI) has been recommended as an important strategy toward it. This article aims to analyze the design, expected benefits and challenges of realizing the goals of UHC through the recently launched SHI in Nepal. On top of the earlier free health‐care policy and several other vertical schemes, the SHI scheme was implemented in 2016 and has reached population coverage of 5% in the implemented districts in just within a year of implementation. However, to achieve UHC in Nepal, in addition to operationalizing the scheme, several other requirements must be dealt simultaneously such as efficient health‐care delivery system, adequate human resources for health, a strong information system, improved transparency and accountability, and a balanced mix of the preventive, health promotion, curative, and rehabilitative services including actions to address the social determinants of health. The article notes that strong political commitment and persistent efforts are the key lessons learnt from countries achieving progressive UHC through SHI.     

吸引和留住农村卫生人力的国际经验及启示

农村地区缺少卫生人力资源是各国普遍面临的问题。本文在文献复习的基础上,利用已有研究证据,介绍和分析了教育类、强制性、经济激励性以及管理和支持性四大类干预措施的内容和效果。文章提出:(1)各国在选择干预措施时,应认真设计,选择适当的干预组合;(2)应该加强干预措施的监督和评估,从吸引、招募、留用以及卫生人力和卫生系统绩效四个维度对干预措施的效果进行系统的评估;(3)应该重视干预措施实施的背景和环境。在此基础上,本文讨论了国际经验对中国的启示,在目前条件下,经济激励性干预措施和教育类干预措施应该成为首要的政策选择,但最终要依靠缩小城乡差异来解决农村地区卫生人力短缺的问题。     

应对卫生人力挑战： 国际视角下的关键问题

卫生人力资源投入短缺和地区分布不均是低收入国家贫困人口不能获得卫生服务的主要原因。本文回顾了近期国际卫生人力政策研究的动向,探讨了加强卫生人力资源的几个关键问题,并且列举了一些旨在应对卫生人力挑战的可能举措。     

The implication of the shortage of health workforce specialist on universal health coverage in Kenya

Background

Globally, there is an acute shortage of human resources for health (HRH), and the greatest burden is borne by low-income countries especially in sub-Saharan Africa and some parts of Asia. This shortage has not only considerably constrained the achievement of health-related development goals but also impeded accelerated progress towards universal health coverage (UHC). Like any other low-income country, Kenya is experiencing health workforce shortage particularly in specialized healthcare workers to cater for the rapidly growing need for specialized health care (MOH Training Needs Assessment report (2015)). Efficient use of the existing health workforce including task shifting is under consideration as a short-term stop gap measure while deliberate efforts are being put on retention policies and increased production of HRH.

Methods

The Ministry of Health (MOH) with support from the United States Agency for International Development-funded FUNZOKenya project and MOH/Japan International Cooperation Agency (JICA) project conducted a country-wide training needs assessment (TNA) to identify skill gaps in the provision of specialized health care in private and public hospitals in 46 out of Kenya’s 47 counties between April and June 2015. A total of 99 respondents participated in the TNA. Structured questionnaires were used to undertake this assessment. The assessment sought to determine the extent of skill gaps on the basis of the national guidelines and as perceived by the County Directors of Health (CDH). The questionnaires were posted to and received by all the respondents a week prior to a face-to-face interview with the respondents for familiarization. Data analysis was done using SPSS statistical package.

Results

Overall, the findings revealed average skill gaps on selected specialists (healthcare professional whose practice is limited to a particular area, such as a branch of medicine, surgery, or nursing, especially, one who by virtue of advanced training is certified by a specialty board as being qualified to so limit his or her practice, Free dictionary) at 85 and 62% when compared to the guideline and as perceived by the CDH respectively. It also revealed that gynecologists exceeded the requirements by 88 and 246% against the guidelines and as perceived by the CDH respectively.

Conclusion

There is an overall huge gap in health specialists across the 46 counties, and the focus of training should be on the following specialists: cardio-surgeons, neurosurgeons, oncologists, nephrologists, lung and skin clinical officers, anesthetic clinical officers, cardiology nurses, forensic nurses, dental nurses, accident and emergency nurses, and oncology nurses. More innovative approaches, including the use of technology, need to be considered to address this challenge in the immediate, medium, and long terms. Policies and legal frameworks should be developed to facilitate cross-county sharing of specialist expertise. Efforts need to be made to ensure harmonized skill gaps revealed by the guideline and as perceived by the CDHs to inform the development of mitigation strategies.

     

积极生育支持背景下不孕不育医疗保障政策国际比较研究

本文基于全民健康覆盖框架,从人群覆盖广度、服务覆盖宽度和费用覆盖深度三个维度,比较了12个国家的不孕不育医疗保障政策异同与效果。为全面构建积极生育支持体系,应针对我国不孕不育高发、医疗费用高昂的社会人口问题,借鉴国际经验,完善不孕不育医疗保障顶层设计,构建多层次保障体系;明确覆盖患者的纳入标准;动态调整医疗服务清单;综合考虑政策目标、筹资能力和患者需求等因素科学制定适宜费用保障标准。多元协同为不孕不育患者提供充分的经济支持,推动实现适度的生育水平。     

Financing health care in Bangladesh: Policy responses and challenges towards achieving universal health coverage

Bangladesh has attained notable progress in most of the health indicators, but still, health system of the country is suffering badly from poor funding. Issues like burden of out‐of‐pocket expenditure, low per capita share in health, inadequate service facilities, and financial barriers in reducing malnutrition are being overlooked due to inadequacy and inappropriate utilization of allocated funds. We aimed to review the current status of health care spending in Bangladesh in response to national health policy (NHP) and determine the future challenges towards achieving universal health coverage (UHC). National health policy suggested a substantial increase in budgetary allocation for health care, although government health care expenditures in proportion to total public spending plummeted down from 6.2% to 4.04% in the past 8 years. Overall, 67% of the health care cost is being paid by people, whereas global standard is below 32%. Only one hospital bed is allocated per 1667 people, and 34% of total posts in health sector are vacant due to scarcity of funds. The country is experiencing demographic dividend with a concurrent rise of aged people, but there seems no financial protection schemes for the aged and working age populations. Such situation results in multiple obstacles in achieving financial risk protection as well as UHC. Policy makers must think effectively to develop and adapt systems in order to achieve UHC and ensure health for all.     

The dynamics of the health labour market

One of the most important components of health care systems is human resources for health (HRH)--the people that deliver the services. One key challenge facing policy makers is to ensure that health care systems have sufficient HRH capacity to deliver services that improve or maintain population health. In a predominantly public system, this involves policy makers assessing the health care needs of the population, deriving the HRH requirements to meet those needs, and putting policies in place that move the current HRH employment level, skill mix, geographic distribution and productivity towards the desired level. This last step relies on understanding the labour market dynamics of the health care sector, specifically the determinants of labour demand and labour supply. We argue that traditional HRH policy in developing countries has focussed on determining the HRH requirements to address population needs and has largely ignored the labour market dynamics aspect. This is one of the reasons that HRH policies often do not achieve their objectives. We argue for the need to incorporate more explicitly the behaviour of those who supply labour--doctors, nurses and other providers--those who demand labour, and how these actors respond to incentives when formulating health workforce policy.     

泰国全民健康覆盖经验及对我国的启示

本文介绍了泰国全民健康覆盖的经验及其对中国的启示。泰国于2001年通过"30泰铢计划"实现了全民健康覆盖。泰国全民健康覆盖显著的特点表现在三个方面,分别是区域医疗联合体为基础的服务提供体系,强调基层医疗卫生服务的核心作用,以及通过按人头支付等措施合理配置卫生资源。有研究证据表明泰国实施全民健康覆盖后,卫生系统绩效得到显著改善。我国在实现全民健康覆盖的过程中,可借鉴泰国经验,加强政府的政治承诺,强化基层卫生服务体系建设,开展协调的综合改革。     

Priority-setting for achieving universal health coverage

Governments in low- and middle-income countries are legitimizing the implementation of universal health coverage (UHC), following a United Nation’s resolution on UHC in 2012 and its reinforcement in the sustainable development goals set in 2015. UHC will differ in each country depending on country contexts and needs, as well as demand and supply in health care. Therefore, fundamental issues such as objectives, users and cost–effectiveness of UHC have been raised by policy-makers and stakeholders. While priority-setting is done on a daily basis by health authorities – implicitly or explicitly – it has not been made clear how priority-setting for UHC should be conducted. We provide justification for explicit health priority-setting and guidance to countries on how to set priorities for UHC.     

Community health workers for universal health-care coverage: from fragmentation to synergy

To achieve universal health coverage, health systems will have to reach into every community, including the poorest and hardest to access. Since Alma-Ata, inconsistent support of community health workers (CHWs) and failure to integrate them into the health system have impeded full realization of their potential contribution in the context of primary health care. Scaling up and maintaining CHW programmes is fraught with a host of challenges: poor planning; multiple competing actors with little coordination; fragmented, disease-specific training; donor-driven management and funding; tenuous linkage with the health system; poor coordination, supervision and support, and under-recognition of CHWs’ contribution.The current drive towards universal health coverage (UHC) presents an opportunity to enhance people’s access to health services and their trust, demand and use of such services through CHWs. For their potential to be fully realized, however, CHWs will need to be better integrated into national health-care systems in terms of employment, supervision, support and career development. Partners at the global, national and district levels will have to harmonize and synchronize their engagement in CHW support while maintaining enough flexibility for programmes to innovate and respond to local needs. Strong leadership from the public sector will be needed to facilitate alignment with national policy frameworks and country-led coordination and to achieve synergies and accountability, universal coverage and sustainability. In moving towards UHC, much can be gained by investing in building CHWs’ skills and supporting them as valued members of the health team. Stand-alone investments in CHWs are no shortcut to progress.     

Strengthening human resources for health through information,coordination and accountability mechanisms: the case of the Sudan

Problem

Human resources for health (HRH) in the Sudan were limited by shortages and the maldistribution of health workers, poor management, service fragmentation, poor retention of health workers in rural areas, and a weak health information system.

Approach

A “country coordination and facilitation” process was implemented to strengthen the national HRH observatory, provide a coordination platform for key stakeholders, catalyse policy support and HRH planning, harmonize the mobilization of resources, strengthen HRH managerial structures, establish new training institutions and scale up the training of community health workers.

Local setting

The national government of the Sudan sanctioned state-level governance of the health system but many states lacked coherent HRH plans and policies. A paucity of training institutions constrained HRH production and the adequate and equitable deployment of health workers in rural areas.

Relevant changes

The country coordination and facilitation process prompted the establishment of a robust HRH information system and the development of the technical capacities and tools necessary for data analysis and evidence-based participatory decision-making and action.

Lessons learnt

The success of the country coordination and facilitation process was substantiated by the stakeholders’ coordinated support, which was built on solid evidence of the challenges in HRH and shared accountability in the planning and implementation of responses to those challenges. The support led to political commitment and the mobilization of resources for HRH. The leadership that was promoted and the educational institutions that were opened should facilitate the training, deployment and retention of the health workers needed to achieve universal health coverage.     

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.     

Health workforce monitoring in Portugal: Does it support strategic planning and policy-making?

The quality of the available information on Human Resources for Health (HRH) is critical to planning strategically the future workforce needs. This article aims to assess HRH monitoring in Portugal: the data availability, comparability and quality.A scoping review of academic literature was conducted, which included 76 empirical studies. The content analysis was guided by the World Health Organization ‘AAAQ framework’ that covers availability, accessibility, acceptability and quality of the health workforce.The analysis identified three types of problems affecting HRH monitoring in Portugal: insufficient data, the non-use of available data, and the general lack of analysis of the HRH situation. As a consequence, the data availability, comparability and quality is poor, and therefore HRH monitoring in Portugal makes strategic planning of the future health workforce difficult.Recommendations to improve HRH monitoring include: 1) make data collection aligned with the standardized indicators and guidelines by the Joint Eurostat-OECD-World Health Organization questionnaire on Non-Monetary Health Care Statistics; 2) cover the whole workforce, which includes professions, sectors and services; 3) create a mechanism of permanent monitoring and analysis of HRH at the country level.     

Squaring the cube: Towards an operational model of optimal universal health coverage

Universal Health Coverage (UHC) has become a key goal of health policy in many developing countries. However, implementing UHC poses tough policy choices about: what treatments to provide (the depth of coverage); to what proportion of the population (the breadth of coverage); at what price to patients (the height of coverage). This paper uses a theoretical mathematical programming model to derive analytically the optimal balance between the range of services provided and the proportion of the population covered under UHC, using the general principles of cost-effectiveness analysis. In contrast to most CEA, the model allows for variations in both the costs of provision and the social benefits of treatments, depending on the deprivation level of the population. We illustrate empirically the optimal trade-off between the size of the benefits package and the proportion of the population securing access to each treatment for a hypothetical East African country, based on WHO data on the costs and benefits of treatments at different coverage levels. We begin with a scenario allowing coverage levels to vary, then apply differential equity weights to the benefits of coverage, and finally illustrate a scenario where interventions are either provided at 95% coverage or not at all (as is usually done in health benefits package design) for comparison. The results present the optimal trade-off between the social benefits of pursuing full population coverage, at the expense of expanding the benefits package for ‘easier to reach’ populations.