Critical challenges for human resources in health: a regional view

Abstracts

Este texto apresenta o contexto e antecedentes, a metodologia e alguns dos principais resultados da Consulta Regional sobre os desafios críticos dos recursos humanos em saúde na Região das Américas. A Consulta, realizada em junho e julho de 2005, foi parte da estratégia da Organização Pan-Americana de Saúde (OPS/OMS) para a organização da VII Reunião Regional dos Observatórios de Recursos Humanos, realizada em Toronto (Canadá). São apresentados os principais resultados e algumas das sugestões encaminhadas pelos atores consultados em relação ao papel da cooperação internacional nos países da Região, a fim de que os países e as agências internacionais formulem estratégias comuns de desenvolvimento e fortalecimento da força de trabalho em saúde.

recursos humanos em saúde; redes comunitárias; Americas

Este texto presenta el contexto y antecedentes, la metodología y algunos de los principales resultados de la Consulta Regional sobre los desafíos críticos de los recursos humanos en salud en la Región de las Américas. La Consulta, realizada en junio y julio de 2005, hizo parte de la estrategia de la Organización panamericana de Salud (OPS/OMS) para la organización de la VII Reunión Regional de los Observatorios de Recursos Humanos, realizada en Toronto (Canadá). Se presentan los principales resultados y las sugerencias formuladas por los actores consultados en relación al papel de la cooperación internacional en los países de la Región, a fin de que los países y las agencias internacionales puedan formular estrategias comunes de desarrollo y fortalecimiento de la fuerza laboral en el campo de la salud.

recursos humanos en salud; redes comunitarias; Américas

SPECIAL ARTICLE

Critical challenges for human resources in health: a regional view

Felix Rigoli^I; Cristianne Famer Rocha^II; Allison Annette Foster^III

^IMestre em Saúde Pública, Mestre em Administração de Saúde, Assessor Regional da Organização Pan-Americana de Saúde (OPS/OMS), e-mail: [e-mail]

^IIDoutora em Educação, Mestre em Educação, Técnica em Educação junto ao Grupo Hospitalar Conceição (GHC), e-mail: [e-mail]

^IIIConsultora Temporária da Organização Pan-Americana de Saúde (OPS/OMS), e-mail: [e-mail]

ABSTRACT

This text presents the context and background, the methodology and some of the main results of the regional consultation on the critical challenges for human resources in health in the Americas. The Consultation, carried out in June and July 2005, was part of the strategy of the Pan American Health Organization (PAHO/WHO) for the organization of the VII Regional Meeting of the Observatories of Human Resources, held in Toronto (Canada). The main results and suggestions by the actors consulted with regard to the role of international cooperation in the countries of the Region are presented, so that the countries and international agencies can better formulate common strategies of development and strengthening of the work force in health.

DESCRIPTORS: health, manpower; challenges; community networks; Americas

CONTEXT AND BACKGROUND

During the 1990's, health systems in the Americas underwent a profound transformation. Trends toward decentralization led to significant structural reforms in the health systems network and in the way that services were provided. The most notable changes included: 1) the separation of financial management from service delivery responsibilities; 2) the introduction of market mechanisms into the system; and 3) the role of the state, which now delegated more authority to the local government levels.

Despite these reforms, however, problems in the health systems have persisted and, in some cases - such as the inequity in the access to the services, the neglect with the aspects of public health, the difficulty of the health authorities in leading the sector -, shaping the main themes for directing the regional agenda for the coming years.

Most of the problems of this general agenda are associated - in one way or another - with human resources. The changes in the structures of the health systems brought about by these reforms have depleted the human resource capacities, and the countries have begun to understand that, without changes in the service delivery practices and the capacities of these health workers, the reforms will not produce the desired effects and, even worse, they will bring about more problems.

With the aim to bring together the countries of the Americas to commit to a coordinated effort, the Pan American Health Organization (PAHO), Health Canada, and the Ministry of Health and Long-term Care of Ontario jointly organized the 7th. Regional Meeting of the Observatories of Human Resources in Health¹ in Toronto, Canada, October 4-7, 2005, to define strategies for overcoming the critical challenges to the development of human resources for health.

The purpose of the Toronto Meeting was to build a consensus among the countries of the Americas with regard to the strategic orientations that will guide the preparation of national action plans that will allow the countries of the Region—individually and collectively—to achieve their priority human resources development goals and to overcome the most pressing human resources challenges over the next ten years—the "Decade of Human Resources in Health."²

To this end, each participating country was invited to develop a national analysis, with the collaboration of relevant stakeholders, to identify both the long term objectives for development and management of human resources, as well as immediate objectives for addressing the most critical problems/needs.

Each country has particular problems and imbalances in its health workforce and, many times, these problems and imbalances affect differently the different regions within the same country. For example:

- Few countries have been able to satisfactorily define a human resource strategy and a long-range political stance to confront their human resources problems.

- Many countries of the Region at different developmental levels consider available quantity, quality, and capability of health personnel inadequate to the address the country's needs.

- The shortages and the displacements of health personnel, particularly those professionals critical to the provision of adequate health services, make it impossible, in many cases, for countries to maintain even the most basic levels of care, especially in the priority activities in the neediest areas of the country.

- Even though there is no doubt that health personnel performance is a key factor in achieving the collective health goals for the population, few countries consider the management of their workforce or the processes for hiring, compensation and incentives, as important aspects of responding adequately to the system's needs.

- Even in those countries where the quantity of health workers is sufficient, the systems of management of the work process and labor relations do not always make it possible for these workers to offer the best quality services in the most productive manner.

- Even though there are many examples of cooperation among the health services organizations, the academic sector and the health authorities, seldom are the efforts coordinated enough to accomplish a needs-based education plan that develops the necessary competencies to fit the objectives of the national policies.

- The planning and regulation of human resources seems to be primarily a function of the State, wherein the State, or more specifically the Ministries of Health, maintain the control and direct decision-making capacity as to the direction and initiatives of the health system activities. However, this arrangement may not be the case in a large number of countries, where the market has a preponderant influence on the functioning of the health services.

ABOUT THE PROCESS OF THE CONSULTATION

During the months of June and July 2005, the Human Resources for Health Unit (HRH) of PAHO/WHO led a consultation to explore the critical challenges in relation to the management and education of human resources in health. Consultation Questionnaire Forms or "Formulários" were sent to focal points, designated by the Health Authorities in each of the 28 countries of the Region. Of these 28 countries, 26 (92.8%) participated in the consultation process (24 country focal points submitted the actual completed forms while two country representatives submitted complementary documents containing the requested information). The countries that submitted responses to the Consultation were:

Argentina, Bahamas, Barbados, Belize, Bolivia, Brazil, Canada, Chile, Colombia, Costa Rica, Cuba, Ecuador, El Salvador, Guatemala, Guyana, Haiti, Honduras, Jamaica, Mexico, Panama, Paraguay, Peru, Dominican Republic, Suriname, Trinidad & Tobago and Uruguay.

The consultation was based on five critical challenges (to be described below), and sought to achieve the following:

- to evaluate the relevant importance of the posed challenges in each country

- to evaluate the current status of each country with regard to each of the challenges.

- to recommend strategies that might be common for the Region for the purpose of improving the situation with regard to each of the challenges.

Furthermore, for each of the challenges, a given number of conditions were presented, considered necessary to overcome that challenge. The consulted actors were asked to give their opinions on which of the defined conditions was the most necessary in order to be able to overcome each challenge; and, of those conditions, into which had the country invested resources or carried out concrete actions.

The consulted actors were asked to qualify the degree of development in their country with regard to this challenge on a scale of 1 to 5 (one meaning no development at all, and five meaning satisfactory development), and then the results were consolidated in averages for the region and several sub regions.

The analysis performed had as its objective to define/clarify, within the parameters of five established "critical challenges," the importance of the themes presented to the stakeholders and other relevant actors who were consulted. Thus, this undertaking was intended as a program of joint collaboration—to be carried out internally, within each of the individual countries, and to be coordinated intra-regionally, among the countries of the Region, and finally among the country stakeholders and the agencies and international development organizations—to be constructed on the basis of the recommendations resulting from these comprehensive consultation processes.

The hope is that, through the collection of country profiles, along with the supporting information coming out of the consultations, pathways will be illuminated by which it may be possible to move forward toward overcoming the critical challenges posed:

1. To define long-term policies and plans to adapt the workforce to the expected changes in the health systems and to develop the institutional ability to implement these changes and regularly review and improve the systems.

2. To place the right people in the right places, achieving an equitable distribution of health professionals and skill sets throughout all geographic areas of the regions and an allocation of skill sets that meet the different needs of each population.

3. To develop mechanisms to manage and regulate the movements of health professionals out of needy areas and to mitigate the negative consequences of those inevitable movements. At the same time, develop systems to benefit from immigration of health professionals into the country.

4. To generate cooperative relationships between the workers and the health organizations that encourage and promote commitment to the institutional mission to guarantee quality health services for all of the population.

5. To develop mechanisms of interaction between the academic and training institutions (universities, schools) and the health services so that it is possible to adapt the education of the health workers to a model of universal equitable care at a quality level that serves the health needs of the population.

ABOUT THE MAIN RESULTS

This Consultation hopefully has documented how the countries in the Americas are facing the main challenges to the development of the health workforce. It is not our intention here to address all the information that was gathered in this process, both in relation to the quantitative results and the richness of opinions given in the open questions³. Our purpose is to mark the main findings, regarding the most and less developed aspects, in order to prioritize lines of action to be considered in future strategies.

Of the five challenges aforementioned, there had been less effort or investment across the Region as a whole toward overcoming the one that was formulated as: "To regulate the displacements of the health workers, both with regard to the internal movements (those within the country) and to the international migrations, so as to ensure access to health care for the entire population". At the same time, it was considered that this challenge would be solved when: "there are still displacements and migrations of health professionals between countries and regions, but there are known trends of these movements, and there are mechanisms that make it possible to adjust the quantity and the make-up of professionals. In addition, there are systems of incentives and job creation, which make it possible to compensate for these movements so that they do not compromise the health services in those areas of greatest need".

This challenge, for all consulted countries of the Region of the Americas, is the major priority, in view of the fact that it is the challenge regarding which there is the least development (an average of 2.23 on a scale of 1 to 5) but with differences between the predefined sub regions⁴.

To overcome this challenge, all countries consulted considered necessary the conditions that are posed in this consultation, although it is suggested to take into account the following:

1st Condition:

There should be monitoring of both internal displacements and international migrations of health workers as well as of the trends of internal and external migration of the principal known professions.

Level of Development (from 1 to 5): 2.18

2nd Condition:

There should be international agreements that regulate professional activities of the workers and that regulate those movements of workers—going out or coming into their country—that are most common and most frequent.

Level of Development (from 1 to 5): 2.27

A comparison of these two conditions, in relation to the countries of the Region, can be seen in the following graph:

The challenge that is considered to be the best developed in the Region was number 2, defined as: "To place the right people in the right places, achieving an equitable distribution of the health workers in the varying regions and in accordance with the varied health needs of the population". This challenge is considered solved when: "The availability of health workers in relation to the citizens/clients allows equitable access to health services to the entire country, including greater availability to those populations with the greatest need."

The response to this challenge has been better addressed in the Region, with an average for the Region of 2.92 on a scale of one to five. Specifically, many countries have developed some process to collect information on the distribution of numbers of workers as this distribution relates to the population they serve and the health goals of the country.

In order to overcome this challenge, all the consulted countries consider necessary the indicated conditions, but suggest or observe the following:

1st Condition:

There should be information on the distribution of quantity of workers in relation to the population that they serve, throughout the entire country and within each of the geographical units (states and localities). The distribution of health personnel must also describe how this workforce is distributed among public and private sectors, and how is it aligned with the health goals and how it contributes to attaining the Millennium Development Goals (MDGs).

Level of Development (from 1 to 5): 3.18

2nd Condition:

There should be information on the use of the workforce at different levels of care and in the different priority programs (for example, the percentage of workers in primary and community care in relation to the percentage of workers in hospitals, or the percentage of workers in individual care services in relation to the percentage of workers in public health services)

Level of Development (from 1 to 5): 3.09

3rd Condition:

There needs to be political commitment and effective plans to mobilize and attract health workers to those regions with the greatest needs.

Level of Development (from 1 to 5): 2.55

4th Condition:

There should be resources and opportunities to readjust the budgets of personnel expenses of the Ministries (or Secretariats) of Health and of other public authorities in accordance with the principal needs of the population.

Level of Development (from 1 to 5): 2.86

This condition depends on the systems of financing in the health services of each country. In Brazil, there are legal mandates that determine the minimal investments for the federal, state and municipal budgetary contributions to the health system. In Costa Rica, on the other hand, the national budgets and public service payroll are more related to the macroeconomic constraints than linked to the health needs. In the case of Honduras, this condition is linked to the high costs of labor since the expenditures for personnel represent 70% of the health budget and the trade associations and unions would not approve it.

A comparison of these conditions, in this group of countries of the Region, can be demonstrated in the figure below.

With regard to what countries have already committed through investments or through actions to overcome this challenge, the following observations should be noted:

- Barbados has invested enough, over the last years, into the development of primary care systems that are free to all Barbadians. These systems can be considered to be staffed with well trained professionals. However, the epidemiological trends are changing, and it will become necessary to guarantee that these professionals keep improving their knowledge and skills for the emergent diseases as well. (Barbados)

- A new law, called "Health Responsibility," is under discussion to improve the oversight on the use of the health budget. (Brazil)

- The state has invested in the aforementioned processes in different degrees. But the success is not necessarily linked with the overall system mechanics, but also with the functionality of the local and regional leadership. As an example, different regions with different degrees of training of their leaders have correspondingly diverse outputs in terms of human resources performance. In other words, similar restrictions don't necessarily condition similar outputs, due to the influence of different leadership abilities. This means that strengthening local leadership will result in better utilization of investments already in place. At the same time, these efforts would be easily fruitless without an adequate central supervision and regulation. (Guyana)

- Technical and financial resources have been invested into the implementation of the above-mentioned processes, but the information has not been reported and disseminated sufficiently, and the results are not implemented as provisions in the policies. The budgets to meet the needs have not been executed. There are no re-distributions or re-allocations of human resources according to skill profile, suitability and/or professional capacity. (Paraguay)

- The state invested the attention and resources in all the aforementioned processes. However, the information is not used for critical analysis, as is being suggested. (Trinidad & Tobago)

SUGGESTIONS FOR ACTION: THE ROLE OF INTERNATIONAL COOPERATION

For each of the analyzed challenges, the consulted actors were asked to offer suggestions on what kind of support or experiences could be offered or shared by international agencies or by other countries to help their countries overcome these challenges. The answers, in a general way, suggest the following:

In reference to Challenge#1: "Adapt the health workforce to the health needs of the population".

- The international agencies can facilitate the sharing of documented experiences from other countries. (Bahamas)

- Technical support can help to strengthen the leadership role of Health Ministries in making decisions. It can also support the strengthening of local capacities to be able to produce information on the existing workforce at the local level, and to be able to exchange successful experiences. (Bolivia)

- Support is needed for a better understanding of experiences of health human resources planning in other countries. (Brazil)

- The exchange of informaton and data on human resources and establishing better practices / tools in planning the health workforce. Establish opportunites through PAHO and WHO to work with other countries on workforce planing issues and thus drive the common agenda into the PAHO and WHO debates. (Canada)

- To know about positive experiences in each of the countries that have developed the human resources topic—the coordination between the academics / trainers and the employers, the management of labor conflicts, and the negotiation with labor unions, among others. (Costa Rica)

- Support for the automation of human resources information. (Cuba)

- There is a great need to improve inadequate capacity through training and re-training of the workforce. There is an acute shortage of well-trained educators that provide professional training programs and that prepare more trainers to be able to sustain the education programs. Support for critical training could stimulate further educational development and thus accomplish sustainable training programs that would continue even after foreign support no longer exists. For example, in the adaptation of existing professional categories in order to provide new aptitudes when there are environmental changes; or the creation of new categories more in line with the existing needs and limitations of the system. (Guyana)

- The agencies should contribute: to motivate the re-structuring of the role of human resources so that it is considered to be a main function of support for the success of health sector reforms; to achieve the adequate placement and distribution of resources in health to where they are actually needed; to support the role of the State Authorities in applying existing experiences to stimulate the creation of legal frameworks; to demand minimum conditions that guarantee transparency in investment mechanisms (Peru)

- The agencies should help in the construction of administrative career tracks for the health sector; they should help with the development of an inter-sectoral and multi-disciplinary plan that leads to the development of human resources in health in the countries; they should support exchange of experiences between countries and they should provide a positive influence to the political processes for encouraging decisions that will improve the workforce. (Dominican Republic)

In relation to Challenge # 2: "To place the right people in the right places, achieving an equitable distribution of health workers across the different regions of the country and matching the varying needs of the population".

- Advocate for a planned sectoral policy that will stimulate the distribution of the professional opportunities into the more remote locations with a ranking system, so that specialties are adequately distributed throughout the entire national territory. (Argentina)

- Support for specialists to coordinate training workshops on human resources information and planning, and program these workshops in countries where there is major development in these areas. (Chile)

- To consider and to learn from some of the experiences of others who have achieved a process for resolving problems of equity, focusing on the management of these types of strategies. More than this, the institutions that can intervene in these processes are those that can provide economic resources for training, to develop study programs aimed at training human resources in these processes. (Costa Rica, El Salvador)

- There is a proposal of a new health employees' career track, driven by PAHO and by the local and provincial Councils of Health Management and the country has adopted the proposal of PAHO, the International Labor Organization and ECLAC developing the Observatories of Human Resources in Health. Support is needed from countries like Brazil, Canada, Cuba, Costa Rica, Colombia and Chile—and in this last case, where health careers apply and there are family care models. (Ecuador)

- To confront the challenge of workforce distribution, so that it effectively meets the range of needs of the entire population, the international organisms will have to help us improve our capacity to build up a large enough number of professionals so that it will be sufficient to eliminate the current gaps and to accommodate for the losses resulting from natural migration. This support has two aspects: 1. to provide, in the short term, trainers that can deliver targeted programs for professional skill training; 2. to strengthen simultaneously the training abilities of our local trainers to secure our capacity to maintain those training programs when the external trainers have returned to their own countries. As natural migration continues to be the major challenge to maintaining a sustainable, stable distribution of the workforce, so that it meets the health needs of the population, the experiences and specialized knowledge of the international institutions in the area of migration management are very useful. (Guyana)

- Training and evaluation, mainly for the purpose of maintaining effective controls. (Haiti)

- To invest in continuing and organized education; to gain from and systematize external experiences, particularly if they are from Latin countries; to take care that the activities do not end with the completion of the external cooperation project, so that the experiences can be institutionalized. (Peru)

In reference to Challenge #3: "To regulate the displacements of health workers, as much in reference to the internal movements (within the country) as to the international migrations, in a manner that will continue to ensure that all the population has access quality health care".

- The international organizations and agencies can provide technical assistance in the development of retention strategies and of training of health professionals, including exchange programs and opportunities for inter-disciplinary training that promote the future development of the aptitudes of health professionals. (Bahamas)

- Information about the experiences and the international measures adopted to diminish the repercussions of the external migration. (Barbados)

- To share information regarding the characteristics and the trends of the migration of health professionals and of the international efforts to manage this phenomenon. To provide opportunities through PAHO and the larger WHO network to work with other countries on developing the competencies of the workforce, the training, the granting of licenses, and the planning for the shared interest that results in common policies for debate/ adoption in the WHO and PAHO discussion. (Canada)

- It would be desirable to know the experiences or agreements that exist between the countries that have received personnel and the countries from which the human resources have emigrated. It would also be beneficial to know, from those countries that have received the health personnel, how and in what areas the countries have benefited from this immigration. (El Salvador)

- There should be better information, such as the offering of on-line courses and management training. Support should be given to the construction of integrated systems of continuing education that are sustainable. (Peru)

In relation to Challenge #4: "To generate bonds between workers and health organizations that promote a collective commitment to the institutional mission to ensure that good health services be accessible to the whole population".

- Design of models for the evaluation of learning needs based on current competencies. The development of a system of continuing education. Development of a system of evaluation of the training processes that are used in relation to the satisfaction of the users. (Bolivia)

- Study tours to countries with greater development in these areas. The presence of consultants who provide an external evaluation of the developments of different processes. (Chile)

- Support of the development of the Observatory of Human Resources and information systems by the relative institutions. Support of the continued alliance between academic institutions and services. Exchange of experiences among countries that are facing or will be facing similar problems. Adoption of the appropriate methodologies. Direct technical cooperation to the institutions. Experiences of other countries in matters related to working with professionals and union organizations. (Guatemala)

- More important than external support is the need for local leadership. (Suriname)

In relation to Challenge #5: To develop mechanisms of interaction between training institutions (universities and schools) and health services to allow for the adaptation of training of the health workforce to the model of universal access to equitable and quality care that meets the health needs of the population:

- To share successful experiences. (Canada)

- To learn innovative strategies. (El Salvador)

- Training of professional trainers to design a new curriculum, adaptation to supply and demand, and regulation of the health system. (Haiti)

- Technical support for the training of trainers; financial support, logistical support, and the sharing of international experiences. With the interchange of experiences, it is possible to establish an "operational agency" for regulation. (Peru)

- The main factor impeding the reform systems for human resources planning, development and management is the lack of leadership, vision, and the capacity to execute the Health Sector Plan. Once the execution is initiated, PAHO could help by providing the necessary technical assistance. (Suriname)

CONCLUSION

The experience of this consultation was of great significance, both for the participant stakeholders (representing their countries) and for the compilers of the results. But, at the end of the day, this consultation and its results will be significant if it can be widely disseminated and used to build strategies that take into account the complexities of the issues involved, proposing responsible and ethical ways to solve the challenges, adding to the solutions to the need for citizens' participation.

Similar to the results of the Seventh Regional Meeting of the Observatories, we hope that this consultation can help to reaffirm:

- That the work force is fundamental for the successful execution of health sector policies, both with regard to the actions of the health workers in the promotion of these policies through their direct services to the people, but also with regard to their role in the formation of these policies, which encourages citizen participation in realizing the health objectives of all the countries of the Region of the Americas;

- That active cooperation among all the actors interested in this subject is necessary and that both the country representatives and the agencies that were represented at the Toronto Meeting wish to continue working together on joint activities that promote, strengthen, and develop the health workforce;

- That the adaptation of the work force, so that it matches the health needs of the population, is a very complex activity, because it must take into account both the epidemiological and the sociodemographic changes of the countries; and it requires permanent investments into building mechanisms that enable both medium and long-term planning;

- That the diversity of the countries in the Region requires that individual actions relate to the specific and unique situations of each while, at the same time, being capable of collectively promoting integration and technical cooperation;

- That it is necessary to foster communication among the interested parties, because this communication is of vital importance to achieve the necessary mobilization around the common objective of building sustainable policies of human resources development in the Region;

- That the immediate actions should be oriented to building an agenda for the next decade, and, at the same time, achieving short term results.

Finally, we hope that this consultation may represent a further step for the collective reflections and decision making oriented to effective and sustainable actions for health human resources development in the countries of the Americas.

Recebido em: 1.12.2005

Aprovado em: 3.1.2006

- Discute-se a instituição de uma lei de responsabilidade sanitária que obrigará melhor uso de recursos para tais fins. (Brasil)

1

For more information about the Observatories of Human Resources in Health:

http://www.lachsr.org/observatorio/eng/index.html

2

See: Human Resources for health, overcoming the crisis. Joint Learning Initiative. Harvard University Cambridge, Massachusetts, 2004.

http://www.globalhealthtrust.org/report/Executive_Summary_Portuguese.doc

3

A full report of this Consultation can be accessed through

http://www.observatoriorh.org/esp/pdfs/DesafiosCriticosINGLES_281SET_.pdf

4

The following countries were included in the averages of the Sub-Regions: Andean (Bolivia, Ecuador, Peru); Central America (Costa Rica, El Salvador, Guatemala, Honduras, Dominican Republic); Caribbean (Bahamas, Barbados, Belize, Guyana, Jamaica, Suriname, Trinidad & Tobago); Southern Cone (Argentina, Brasil, Chile, Paraguay and Uruguay). In the Americas averages were also included for: Canada, Cuba and Mexico.

Publication Dates

• Publication in this collection
  08 Mar 2006
• Date of issue
  Feb 2006

History

• Accepted
  03 Jan 2006
• Received
  01 Dec 2005