CRITICAL CHALLENGES FOR HUMAN RESOURCES IN HEALTH: A REGIONAL VIEW

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.


Meeting of the Observatories of Human Resources in
Health* 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."**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 needsbased 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

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Rev Latino-am Enfermagem 2005 janeiro-fevereiro; 14(1) www.eerp.usp.br/rlaesystem 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.The consultation was based on five critical challenges (to be described below), and sought to achieve the following:

ABOUT
-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 intraregionally, 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.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 questions*.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 regions**.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 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.-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.
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:

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.

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Figure 1 -Regulating migrations of the health workforce Figure 3 -Equitable distribution of the health workforce

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comparison of these two conditions, in relation to the countries of the Region, can be seen in the following graph: 1 No Development --------------> 5 Satisfactory Development 28: Monitoring of internal and external migrations 29: International agreements to regulate the migrations

Figure 2 -
Figure 2 -Conditions to regulate health workforce migrations s

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Figure 4 -Conditions for a more equitable distribution of the health workforce 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) Critical challenges to human... Rigoli F, Rocha CF, Foster AA.

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Brasil, Chile, Paraguay and Uruguay).In the Americas averages were also included for: Canada, Cuba and Mexico.Critical challenges to human...Rigoli F, Rocha CF, Foster AA.  www.eerp.usp.br/rlae