Hospitals & Asylums
Review of the World Health Report 2006: Working Together for Health HA-14-4-06
The World Health Report 2006 - Working together for health contains an expert assessment focusing on all stages of the
health workers' career lifespan from entry to health training, to job
recruitment through to retirement, the report lays out a ten-year action plan
in which countries can build their health workforces, with the support of
global partners. WHO estimates
there to be a total of 59.2 million full-time paid health workers worldwide. Almost all
countries suffer from mal-distribution characterized by urban concentration and
rural deficits, but these imbalances are perhaps most disturbing from a
regional perspective. The WHO Region of the
1. In this first decade of the
21st century, immense advances in human well-being coexist with extreme
deprivation. In global health we are witnessing the benefits of new medicines and
technologies. But there are unprecedented reversals. What is needed now is political will to
implement national plans, together with international cooperation to align
resources, harness knowledge and build robust health systems for treating and
preventing disease and promoting population health. At the heart of each and every health system,
the workforce is central to advancing health. There is ample evidence that
worker numbers and quality are positively associated with immunization
coverage, outreach of primary care, and infant, child and maternal survival.
The quality of doctors and the density of their distribution have been shown to
correlate with positive outcomes in cardiovascular diseases. Cutting-edge quality improvements of health
care are best initiated by workers themselves because they are in the unique
position of identifying opportunities for innovation. In health systems,
workers function as gatekeepers and navigators for the effective, or wasteful,
application of all other resources such as drugs, vaccines and supplies. Health service providers are the personification of a system’s
core values – they heal and care for people, ease pain and suffering, prevent
disease and mitigate risk – the human link that connects knowledge to health action. LEE Jong-wook
Director General of the WHO at the High-Level Forum,
2. Financing policies, technological advances and consumer expectations can dramatically shift demands on the workforce in health systems. Workers seek opportunities and job security in dynamic health labour markets that are part of the global political economy. The spreading HIV/AIDS epidemic imposes huge work burdens, risks and threats. Expanding labour markets have intensified professional concentration in urban areas and accelerated international migration from the poorest to the wealthiest countries. The consequent workforce crisis in many of the poorest countries is characterized by severe shortages, inappropriate skill mixes, and gaps in service coverage. Based on these estimates, there are currently 57 countries with critical shortages equivalent to a global deficit of 2.4 million doctors, nurses and midwives to achieve the Health related Millennium Development Goals. This crisis has the potential to deepen in the coming years. Demand for service providers will escalate markedly in all countries – rich and poor. Richer countries face a future of low fertility and large populations of elderly people, which will cause a shift towards chronic and degenerative diseases with high care demands. In poorer countries, large cohorts of young people (1 billion adolescents) will join an increasingly ageing population, both groups rapidly urbanizing. Many of these countries are dealing with unfinished agendas of infectious disease and the rapid emergence of chronic illness complicated by the magnitude of the HIV/AIDS epidemic. The availability of effective vaccines and drugs to cope with these health threats imposes huge practical and moral imperatives to respond effectively.
3. The workforce must be mobilized to address specific health challenges:
The MDGs target the major poverty-linked diseases devastating poor populations, focusing on maternal and child health care and the control of HIV/AIDS, tuberculosis and malaria. Countries that are experiencing the greatest difficulties in meeting the MDGs, many in sub-Saharan Africa, face absolute shortfalls in their health workforce. Major challenges exist in bringing priority disease programmes into line with primary care provision, deploying workers equitably for universal access to HIV/AIDS treatment, scaling up delegation to community workers, and creating public health strategies for disease prevention.
Chronic diseases, consisting of cardiovascular and metabolic diseases, cancers, injuries, and neurological and psychological disorders, are major burdens affecting rich and poor populations alike. New paradigms of care are driving a shift from acute tertiary hospital care to patient-centred, home-based and team-driven care requiring new skills, disciplinary collaboration and continuity of care – as demonstrated by innovative approaches in Europe and North America. Risk reduction, moreover, depends on measures to protect the environment and the modification of lifestyle factors such as diet, smoking and exercise through behaviour change.
Health crises of epidemics, natural disasters and conflict are sudden, often unexpected, but invariably recurring. Meeting the challenges requires coordinated planning based on sound information, rapid mobilization of workers, commandand- control responses, and intersectoral collaboration with nongovernmental organizations, the military, peacekeepers and the media. Specialized workforce capacities are needed for the surveillance of epidemics or for the reconstruction of societies torn apart by ethnic conflict. The quality of response, ultimately, depends upon workforce preparedness based on local capacity backed by timely international support.
4. From policy and management perspectives, the framework focuses on modulating the roles of both labour markets and state action at key decision-making junctures: 1. Entry: preparing the workforce through strategic investments in education and effective and ethical recruitment practices. 2. Workforce: enhancing worker performance through better management of workers in both the public and private sectors. 3. Exit: managing migration and attrition to reduce wasteful loss of human resources. 4. The world’s 1600 medical schools, 6000 nursing schools and 375 schools of public health in aggregate are not producing sufficient numbers of graduates program. Education quality is assured through a process of institutional accreditation and professional regulation (licensing, certification, registration and continuing medical education). Substantial improvements in the availability, competence, responsiveness and productivity of the workforce can be rapidly achieved through an array of low-cost and practical instruments.
Supervision makes a big difference. Supportive yet firm – and fair – supervision is one of the most effective instruments available to improve the competence of individual health workers, especially when coupled with clear job descriptions and feedback on performance. Moreover, supervision can build a practical integration of new skills acquired through on-the-job training.
Fair and reliable compensation. Decent pay that arrives on time is crucial. The way workers are paid, for example salaried or fee-for-service, has effects on productivity and quality of care that require careful monitoring. Financial and non-financial incentives such as study leave or child care are more effective when packaged than provided on their own.
Critical support systems. No matter how motivated and skilled health workers are, they cannot do their jobs properly in facilities that lack clean water, adequate lighting, heating, vehicles, drugs, working equipment and other supplies. Decisions to introduce new technologies – for diagnosis, treatment or communication – should be informed in part by an assessment of their implications for the health workforce.
Lifelong learning should be inculcated in the workplace. This may include short term training, encouraging staff to innovate, and fostering teamwork. Frequently, staff devise simple but effective solutions to improve performance and should be encouraged to share and act on their ideas.
Chapter one: Health Workers A Global Profile gives an
overview of what is known about them. It describes the size and distribution of
the workforce, and some of its characteristics, including how much it costs and
then considers how much it would cost to scale up training to meet the
perceived shortfall and pay health workers.
The third version of the International Standard Classification of Occupations
(ISCO), an international classification system agreed by members of the
International Labour Organization, was adopted in
1987 and is known as ISCO-88. Health
workers are distributed unevenly. Countries with the lowest relative need have
the highest numbers of health workers, while those with the greatest burden of
disease must make do with a much smaller health workforce. In the HIV/AIDS
literature, scaling up treatment with anti-retroviral was estimated to require
between 20% and 50% of the available health workforce in four African
countries, though less than 10% in the other 10 countries surveyed. In more
general terms, analysts estimated that in a best case scenario for 2015 the
supply of health workers would reach only 60% of the estimated need in the
United Republic of Tanzania and the need would be 300% greater than the
available supply in
achieve a global assessment of shortfall, the Joint Learning Initiative (JLI),
a network of global health leaders, launched by the Rockefeller Foundation,
suggested that, on average, countries with fewer than 2.4 health care
professionals (counting only doctors, nurses and midwives) per 1000 population
failed to achieve an 80% coverage rate for deliveries by skilled birth
attendants or for measles immunization.
57 countries that fall below this threshold and which fail to attain the
80% coverage level are defined as having a critical shortage. Thirty-six of
them are in sub-Saharan
7. Chapter two: Responding to Urgent Health Needs challenges are, first, to scale up interventions to attain the health-related MDGs; second, to shift successfully to community-based and patient-centred paradigms of care for the treatment of chronic diseases; third, to tackle the problems posed by disasters and outbreaks; and fourth, to preserve health services in conflict and post-conflict states. A shortage of human resources has replaced financial issues as the most serious obstacle to implementing national treatment plans. National programmes to achieve disease-specific MDGs place many parallel demands
on district health managers and service providers, such as reading documents, filling forms, writing reports, attending meetings and making field visits. In recent years, the traditional focus on acute, inpatient and sub-specialty care has given way to new paradigms of care emphasizing self-management, and community- based patient-centred pre-hospital care. Five core competencies for long-term patient care have been identified: patient-centred care, partnering, quality improvement, information and communication technology and a public health perspective. The challenge is to translate these into practice through the institutions that produce and deploy the health workforce. Changes in the curriculum, new teaching methods, and innovative training models are necessary. A team approach is required not only in the management of individuals with chronic conditions but in addressing these public health challenges more broadly. In general, care for chronic diseases is best delivered with a collaborative effort involving public health specialists, policy and service planners, researchers, information technology designers, and support personnel. The multidisciplinary team in mental health includes psychiatrists, psychologists, nurses, general practitioners, occupational therapists and community/social workers who can share their expertise and collaborate with each other.
Uses and misuses of biomedical and public health knowledge during time of war
or armed conflict are commonplace.
Public health and medical crimes such as diverting medical supplies and
human resources, abuse and torture, medical killing in the name of science, and
eugenics for social goals, have been perpetrated with the complicity of health
and medical professionals in countries such as
Chapter 3: Preparing the Health Workforce is about preparation: getting it
right at the beginning; giving the right training to the right people to create
an effective workforce for the delivery of health care. It focuses on the entry
of health workers into the workforce and on the health training institutions –
schools, universities and training colleges – which provide them with the
knowledge and competencies for the jobs they will be required to do. “Academic medicine” is often defined as a
triad of research, clinical service, and medical education. It might also be
de- fined as the capacity to study, discover, evaluate, teach, and improve
health systems. The specific priorities
related to the number, range and quality of health training institutions are:
the disciplinary mix of institutions, accreditation to maintain standards,
management of the applicant pool, and retention of students through to
graduation. Globally, educational
establishments training health workers are heavily tipped towards the
production of physicians and nurses: 1691 and 5492, respectively, in contrast
to 914 schools of pharmacy, 773 schools of dentistry and 375 schools of public
health. The WHO Eastern Mediterranean and
Lifelong learning and develop relevant workplace competencies that can adapt to
diverse challenges and populations. New
trends in education aim to improve the health of the public by implementing
this idea in training methods practice-based teaching aims to: bridge the gap
between academia and practice; benefit students, schools, agencies and
communities; involve and develop critical thinking and problem solving skills;
be interdisciplinary, multidisciplinary and multidimensional; develop learning
partnerships among academic staff, practitioners and students, to educate
teachers, practitioners and researchers; incorporate experiential education,
including critical reflection, observation and learning by doing. Problem-based learning complements
practice-based teaching through: identifying the problem; exploring
pre-existing knowledge; generating hypotheses and possible mechanisms;
identifying learning issues and objectives; self study and group learning;
re-evaluation and application of new knowledge to the problem; assessment and
reflection on learning. Patient-focused
practice: integrates teaching and learning with clinical practice; shares
experiences of illness, disease and recovery with patients; understands varying
needs for care; observes and participates in the ways in which different
service providers work together to meet the needs of
patients. training pharmacy students. For example the clinical partners programme at the
12. The Integrated Case Management Process for the outpatient health facility is to Check for danger signs such as Convulsions, Lethargy/unconsciousness, Inability to drink/breastfeed or Vomiting. Then to assess the main symptoms such as Cough/difficulty breathing, Diarrhoea, Fever or Ear problems. Then to Assess nutrition, immunization status and potential feeding problems. Then to Check for other Problems, Classify conditions and identify treatment actions According to coded treatment methods. Outpatient health facilities are responsible for Urgent referral, Pre-referral treatments, Advise parents and Refer child. The physician is also responsible for the treatment at outpatient health facility, treating local infection, Giving oral drugs, Advising and teaching caretakers, Follow-up. Home based care involves, Home management whereby the Caretaker is counseled on how to: Give oral drugs, Treat local infections at home, Continue feeding, When to return immediately, Follow-up. Referrals to hospital facilities occur for: Emergency triage and treatment (ETAT), Diagnosis, Treatment and Monitoring and follow-up.
13. Chapter four: Making the Most of Existing Health Workers. A country’s health workforce is made up of health workers who are at many different stages of their working lives; they work in many different organizations and under changing conditions and pressures. Whatever the circumstances, an effective workforce strategy has to focus on three core challenges: improving recruitment, helping the existing workforce to perform better, and slowing the rate at which workers leave the health workforce. Strategies to boost worker performance are critical for four reasons: 1.They will be likely to show results sooner than strategies to increase numbers. 2. The possibilities of increasing the supply of health workers will always be limited. 3. A motivated and productive workforce will encourage recruitment and retention. 4. Governments have an obligation to society to ensure that limited human and financial resources are used as fairly and as efficiently as possible.
14. For many years it was assumed that poor health worker performance was primarily caused by a lack of knowledge and skills. In recent years this perception has changed, and three broad groups of factors are now recognized. 1. Characteristics of the population being served: it is simpler to increase immunization coverage or adherence to treatment for tuberculosis or HIV infection where the population understands the benefits and has the motivation and resources to seek services. 2. Characteristics of health workers themselves, including their own socio-cultural background, knowledge, experience and motivation. 3. Characteristics of the health system, and the wider environment, that determine the conditions under which health workers work. These include the inputs available to them to do their jobs, how the health system is organized, how the workers are paid, supervised and managed, and factors such as their personal safety.
15. The performance of health workers, in terms of both competence and responsiveness, is also influenced by their sense of professional identity, vocation and work ethic. The notion of “professionalism” and vocation in health has a long history. Almost every doctor and patient has heard of the Hippocratic Oath, which is the longest surviving ethical code of conduct. It is still sworn by many medical graduates. Health workers are expected to conduct themselves with integrity, selflessly to apply technical know-how and to put the interests of the patient above their own. Supervision, especially coupled with audit and feedback to staff, has been consistently found to improve the performance of many types of health workers, from providers to managers. Supervision must be supportive, educational and consistent and helps to solve specific problems, can improve performance, job satisfaction and motivation.
16. The way people are paid makes
a major difference to what they deliver. Individual health workers, and the
facilities in which they work, can be paid in many different ways. For each,
pay may be time-based (salaries or fixed budgets), service-based (fee for
service) or population-based (per capita payments or block contracts). No matter how motivated and skilled health
workers are, they cannot do their jobs properly in facilities that lack clean
water, adequate lighting, heating, vehicles, drugs, working equipment and other
supplies. Two examples illustrate the
17. Health workers are more motivated to perform well when their organization and managers: provide a clear sense of vision and mission; make people feel recognized and valued whatever their job; listen to staff and increase their participation in decisions – they often have solutions; encourage teamwork, mentoring and coaching; encourage innovation and appropriate independence; create a culture of benchmarking and comparison; provide career structures and opportunities for promotion that are transparent and fair; give feedback on, and reward, good performance – even with token benefits; use available sanctions for poor performance in ways that are fair and consistent. Good managers reward their staff. Some examples of non-financial rewards that may be used are: tea during night duty, holidays and days off, flexible working hours, access to and support for training and education, sabbaticals, study leave, and planned career breaks. Some examples of management and leadership
18. This chapter has described the levers that can influence workforce performance. An inevitable tension exists between the perspectives and goals of individuals and the organizations to which they belong. Organizations have to perform well and deploy their staff to the greatest advantage, while also providing places for individuals to thrive. This tension must be continually monitored and managed. Moreover, managing any change is a subtle and often difficult process, for several reasons. Changes may be needed at several levels. Legal and regulatory frameworks may need to be changed, which can be complex and slow. Resources are often needed to support change. Probably most importantly, local stakeholders must be brought “on board” as they can facilitate or equally effectively block a reform that has been carefully negotiated at central level. However difficult, without changes to support improved performance of existing health workers, any recruitment and retention strategies will have limited effect.
19. Chapter five: Managing Exits from the Workforce. Each year, substantial numbers of health workers leave the health workforce, either temporarily or permanently. These exits can provoke shortages if workers who leave are not replaced, and such shortages compromise the delivery and quality of health services. The main reasons people leave the health workforce are depicted in migration; risk of violence, illness or death; change of occupation or work status; child birth and retirement. High turnover rates in the health workforce may lead to higher provider costs. They are also a threat to the quality of care, because they may disrupt organizational function, reduce team efficiency, and cause a loss of institutional knowledge. Studies show that the costs associated with retention problems are often substantial. Turnover can have potential benefits, however, as it may provide an opportunity to match personnel skills better to workplace needs, facilitate the introduction of new ideas into well established organizations, and increase organizational flexibility. In this context, it is important for policy-makers to manage exits from the health workforce to ensure the least possible disruption of services.
Concerns about the adverse impact of the flows of skilled professionals from
poorer to richer countries have thrust the migration of health workers to the
forefront of the policy agenda in recent years. However, statistics on global
flows of health workers remain far from complete. Each year, 3 million health workers worldwide
are exposed through the percutaneous route to bloodborne pathogens: 2 million are exposed to hepatitis B,
900 000 to hepatitis C and 170 000 to HIV. These injuries result in 15 000, 70
000 and 1000 infections, respectively. More than 90% of these infections occur
in developing countries. In areas where
rates of HIV/AIDS are high, attrition rates of health workers due to illness
and death are alarming. In
21. Chapter six: Formulating national health workforce strategies. The ultimate goal of health workforce strategies is a delivery system that can guarantee universal access to health care and social protection to all citizens in every country. To the general public, the term “health workers” evokes doctors and nurses. While this does not do justice to the multitude of people who make a health care system work, it does reflect the public’s expectations: encounters with knowledgeable, skilled – and trustworthy – doctors and nurses who will help them to get better and who will act in their best interests. Trust is not automatic: it has to be actively produced and negotiated. It is “slowly gained but easily lost in the face of confounded expectations”. In many countries, professional organizations decide who can provide care and how providers should behave. Self-regulation can indeed be effective and positive: professional associations can promote professional ethics and positive role models, sanction inappropriate behaviour, and maintain the technical competence of their members. The way health workers balance their own interests and those of their patients depends to a large extent on what is considered “good professional behaviour” by their teachers and peers. Professional associations can play an active role in shaping that image.
22. Even where regulations exist, governments may have major problems enforcing them. There are three results: first, each year approximately 44 million households worldwide are faced with catastrophic health expenditures; second, many more people are excluded from access to care; and third, this situation favours supply induced over-medicalization.. One example is the high incidence of caesarean sections around the world. Within a single country, mothers with the financial means may be subject to an unnecessary and potentially dangerous intervention, while the same procedure is denied to another who needs it to save her life or that of her baby but who cannot mobilize the funds. In order to ensure public safety and good governance of health care providers, capacity building requires investment in the overall regulatory architecture outlined in. Simultaneous efforts are needed to reinforce the potential contributions of the state and social insurance institutions, as well as those of professional and civil society organizations. This means that, along with the creation of the specific technical bodies for licensing, accreditation and so on, forums must be established that allow for interaction among these various groups, which in turn implies the recognition and support, including financial, of their contributions. National health workforce strategies must move beyond salary and training in the public sector to strategies for the entire work cycle of entry–workforce–exit in both the public and private sectors. Workforce development is both a technical and political exercise, requiring the building of trust among stakeholders and linking people’s expectations with health worker performance.
23. Chapter seven: Working together, Within and Across Countries. There are five broad areas of concern that impel countries to look beyond their borders and work together with others in order to address issues of human resources for health more effectively: 1. The profound lack of information, tools and measures, the limited amount of evidence on what works, and the absence of shared standards, technical frameworks and research methodologies are all imperatives for regional and international collaboration. 2. The scarcity of technical expertise available to develop better metrics, monitor performance, set standards, identify research priorities, and validate methodologies means that a collective global effort is the only way to accelerate progress in these areas. 3. The changes in demographics, demand for care, and technological advances cut across borders and are manifested in increasingly global labour markets. Cooperative arrangements and agreements between countries are essential to manage these flows and minimize adverse effects. 4. The reality that a violent conflict, an outbreak of an infectious disease, or an unexpected catastrophic event can lay waste even to the most well-prepared national health system demonstrates that no country will ever have the human resource capacity to be able always to mount an effective response entirely on its own 5. The enormous workforce crisis that constrains health development so profoundly in the world’s poorest countries requires an international response. This chapter focuses on the rationale for working together and concludes with a plan of action that is based on national leadership and global solidarity.
24. In planning their health workforce strategies, countries cannot overlook the dynamics of the global labour markets affecting health workers. Pushed by population trends towards ageing, changes in consumer expectations and technological innovations, the health sector globally continues to defy expectations in terms of its rate of growth. Demand for service providers will escalate markedly in all countries – rich and poor. The dire situation provoked by the global health workforce crisis requires nothing short of an outstanding global response. International action necessitates: coalitions around emergency national plans for health care providers; health worker-friendly practices among global partners; and sufficient and sustained financing of the health workforce. National strategies on their own, however well conceived, are insufficient to deal with the realities of health workforce challenges today and in the future. Strategies across countries are similarly constrained by patchy evidence, limited planning tools and a scarcity of technical expertise. Outbreaks of disease and labour market inflections transcend national boundaries, and the depth of the workforce crisis in a significant group of countries requires international assistance. National leadership must therefore be complemented by global solidarity. National leadership and global solidarity can result in significant structural improvements of the workforce in all countries, especially those with the most severe crises. Such advances would be characterized by universal access to a motivated, competent and supported health workforce, greater worker, employer and public satisfaction, and more effective stewardship of the workforce by the state, civil society and professional associations.
World Health Report 2006: Working Together for Health. http://www.who.int/whr/2006/en/