Human Resources for Health – a bottleneck for Primary Health Care?

While preparing this paper, I have been thinking whether to use a more common approach to the topic, which would be to provide an overview of health workforce issues in relation to Primary Health Care (PHC) development, including shortages and determinants in many Low and Middle income countries (LMICs). Consecutively we could have a look to strategies in the past and present to overcome issues like the retention of health care workers, maldistribution of health personnel, limited capacity for the education of health workers and possibilities for a balanced response to health workforce migration. 

While I might touch upon some of these aspects later, I rather address the health workforce challenge from another angle, one that is called “Interrogating scarcity: how to think about resource scarce-settings” and described by Ted Schrecker in a 2012 article. [1] Basically, the notion of interrogating scarcity is that scarcity cannot simply be assumed as a given. In an interconnected world, globalization and scarcity are closely linked. Globalization is described in Schrecker's article as “a pattern of transnational economic integration animated by the ideal of creating self-regulating global markets for goods, services, capital, technology, and skills... This Market fundamentalism presumes that markets are the normal and natural basis for organizing almost all areas of human activity; and tends to define citizenship in terms of participation in markets, as a producer and (informed) consumer. Market fundamentalism is the value system at the core of contemporary globalization." Over the last 3 decades, the development of Primary Health Care and health systems have been permeated by this market fundamentalism, and strongly influenced by forces of transnational economic integration. There Is No Alternative, as we can read in Francis Fukuyama's The End of History?[2] Few countries have been trying to come up with alternatives, as we will see, with remarkable results for health outcomes.

What does this all have to do with Health Workforce Development? I must admit that I don't like the term Human Resources for Health, because this term indirectly degrades health workers to a production unit, or in WHO terms a - health systems block - that can be controlled and adjusted by government and market forces. Every health worker is a unique human being that in his/her way, has the potential to contribute to other people's health. WHO has in a sense also downgraded the term health worker. In its World Health Report 2006 (Working together for health), health workers are defined as “to be all people engaged in actions whose primary intent is to enhance health”. But then the report continues: “ However, the data available on health worker numbers are generally limited  to people engaged in paid activities, so the numbers reported in this chapter are limited to such workers”. It then further classifies two types of health workers: “health service providers” and “health management and support workers”.  To further narrow it down, the medical doctor, nurse and midwife are considered professional service providers. When WHO talks about shortage of health workers, it talks mainly about this last professional category. This calculation is based on a minimum threshold of health workers needed for skilled birth attendance and 80% measles coverage; coming to a “floor” of 2.5 health workers per 1000 persons. With this calculation 57 countries (of which 36 in Africa) are considered to have a “critical' shortage. To reach this minimum threshold in all the 57 countries, an additional 4.3 million health workers would be required.[3]  If we interrogate this scarcity, we should explore what its main determinants are.

Task Shifting?

There are sufficient persons available to work on health, although not directly professional educated. Why not work with them? Task shifting to less specialized cadre is an often proposed solution. Brazil has since the '90s good experience with integration of community health worker in their primary health programmes that are based on a more integrated approach whereby community based organizations are involved in decision-making about allocation of resources and in actions that address some upstream determinants of health at the local level. This approach was part of a broader and well-funded health policy. However, in many countries these approaches have remained fragmented, with limited political commitment, genuine participation and long term funding. NGOs, especially in relation to the HIV/AIDS epidemic in Sub-Saharan Africa, have worked enthusiastically with community health workers in relation to health promotion, Voluntary Counseling and Testing and home based care. Despite local successes, uptake by governments to have these “volunteers” integrated in sustainable national programs with proper remunerations and educations has remained limited. [4]  

One of the core reasons why the professional health workforce in many LMICs could not expand has been considerations of macro-economic origin. A good example is Thailand. In the late seventies/ early 80s, due to the social environment, there had been in 10 years a fourfold increase of doctors working in rural areas. Rapid economic growth and a government investment policy, started in the late 1980s, supported private hospital investment with a free flow of low-interest foreign loans, facilitated by the World Bank, and resulted in a rapid growth of the private health sector in the decade from 1988–1997. It created an internal brain within the Thai health system, a second one after an external brain drain from Thai doctors in the 1960s to the United States.[5]

Fiscal space

Over the last 3 decades there has been a strong push for macro-economic stability and growth in LMICs, by means of deregulation and privatization of the economy. Conditions by the World Bank and the International Monetary Fund (IMF) on investment loans and crisis funding, forced countries to open up their economy to foreign investments, as well as a reduction of public spending (austerity) and a strict ceiling on wage bills for public sector employees, such as health workers. The IMF recipe can be described as the shock doctrine (The rise of disaster capitalism) in analogy of the book by Naomi Klein[6]. In current Europe we see that these policies are not contained to LMICs, but that the European Central Bank (ECB), EU and IMF (known as the “Troika”) force countries as Greece, Portugal, Ireland and Spain to reduce their public spending considerably. 

What has been and is the impact on the health workforce?  In ex-communist countries in Eastern Europe there has been a 7 % reduction of doctors per capita in the nineties when its economies opened to the West, as were the numbers of dentists and hospital beds. The IMF in 2007 concluded itself that wage bill ceilings had been overused in its poverty reduction programs. In the period 2003-2005, 17 countries in Africa faced wage bill ceilings. All these countries, amongst which Malawi, Mozambique and Zambia, were and are facing serious health workforce shortages, worsened by the HIV/AIDS crises and health demands. Its public governments could not employ new health staff in that period, because of the ceilings (although the IMF argues that exceptions could have been possible for the health sector). Instead global health partnerships like the GFATM and the PEPFAR initiative provided funds for NGOs and Faith Based Organizations to provide health services in parallel to the public system, which employed the health workers with private and,  too often, short-term contracts.[7]  

In Greece, the current austerity plan approved by the Troika leads to a  reduction of 150.000 jobs in the public sector workforce between 2011 and 2015. The Troika has demanded that public spending on health should not exceed 6% of Gross Domestic Product, which leads to a decrease of 25% of medical doctors employed by the central social security fund, as well as 25% reduction in physicians’ wages. There has been a sharp increase in people that require care, but that could not receive it. In Catalonia, due to austerity closure of health care services and reductions in the number of hospital beds and working hours have been reported. In Portugal public sector employees' income were cut in 2011 and 2012. The expectation is that in Europe, with its free internal labor market, these wage imbalances might lead to an internal European brain drain[8] Indeed, in the Netherlands, with is ageing population in need of chronic care, we have seen Spanish nurses being recruited by agencies for chronic and auxiliary care services..

The ‘fiscal realities’ in many European countries have a serious impact on social programs and wellbeing. The austerity measures that should stabilize national government debts and budget deficits, as to remain attractive and trustworthy for foreign investors provide a smoke screen for real issues of economic scarcity. One such has been the bail-out in several European countries of too-big- to fail financial institutions with public financing. The de-regulation of the financial sector and the lack of accreditation by the governments of its banking products, is one the reasons why the crisis has hit so hard. We could perhaps learn from Iceland that in its 2008 crises decided not to bail out the banks. Iceland ignored the advice of the IMF, and instead invested in social protection. This investment was coupled with active measures to get people back into work. ‘Finally, the Icelandic people drew on strong reserves of social capital, and everyone really felt that they were united in the crisis. Although extrapolation to other countries should be undertaken with care, Iceland, by challenging the economic orthodoxy at every step of its response, has shown that an alternative to austerity exists’. [9] 

Secondly, the fiscal realities that frames available public financing for health systems and health workforce salaries, is shaped by issues as untaxed wealth, capital flight and wealth inequalities. Fewer than 100.00 people –that is 0,0001 % of the world’s population -  now control over 30% of the world’s financial wealth. Data from 139 mostly LMICs shows us that they had an aggregated debt of 4.1 trillion US$ at the end of 2010.  But once you take their foreign reserves and the offshore private holdings of their wealthiest citizens into account, the picture flips into reverse: these 139 countries have aggregate net debts of minus US$10.1-13.1 Trillion US$. So these countries are net creditors to the world, and in a big way. The problem here is that their assets are held by a small number of wealthy individuals, while their debts are shouldered by their ordinary people through their governments[10].

Regarding tax evasion; 23.400 “mailbox” companies are registered in the Netherlands, with its infamous tax heaven industry. It lead for instance to Portuguese and Spanish multinationals to avoid paying tax in their respective countries. As a result of the crises both Spain and Portugal bailed-out banks, and had to severely cut their public spending on health expenditures and health workforce salaries, as we have seen above. A logical conclusion follows, if we want to safeguard our health systems, we should challenge tax evasion and re-invest these financial resources in national social protection schemes including health.

I will not further elaborate on domestic and international migration of health workers from the South to the North, that has been partly the result of  fiscal policies restricting the absorption of health workers in national health systems. There is range of literature on brain drain in relation to health workforce migration, and has been dubbed a “perverse subsidy”. [11]  One author states in an overview paper that ”Global trade liberalization (via WTO “mode 4”)  has led to an international movement of health service providers. This can generate remittances, contribute to the exchange of knowledge among professionals, and provide countries of destination with otherwise unavailable skills. The permanent emigration of health workers may exacerbate health workers shortages in source countries, thus hampering adequate service delivery. Already fragile health systems are further weakened, while public resources invested in their training are lost”.[12]

Solutions for a stronger health workforce

The response by the WHO and the global community on these health workforce “scarcities and imbalances“ have been ambiguous. The Global Health Workforce Alliance (GHWA) has been initiated in 2006, and brings together a wide range of actors, that are looking for multiple-stakeholder solutions both at national and the international level. This has led to considerable attention and funding for training programs as to scale up the health workforce, to  improve national planning capacity and evidence , and programs on task-shifting and the integration of community health workers. The Kampala declaration an agenda for action, emerging from the first global forum on human resources for health in 2008, indicates 6 areas that require attention, including the points above but also managing the pressure of the international health workforce market and retaining an equitably distributed health workforce[13]. WHO has and is providing technical guidance on the retention of health workers to rural areas, as well as guidelines to scale-up the workforce. Donors like USAID, DFID and JICA have invested considerably in the training of community and professional health workers, in countries as diverse as Malawi, Bangladesh and Ethiopia. Most importantly, the WHO has brokered a Global Code of Practice on the international recruitment of health personnel that has been adopted at the World Health Assembly in 2010.[14] In this Code WHOs 194 member states  have agreed to address the global and ethical dimensions of health workforce migration. The code provides guidance to more fair and rights based approach to the recruitment of health workers. Three years after adoption of the voluntary code it has been mainly European countries that submitted a progress report to WHO and undertook (some) action. 

Although WHO and the GHWA call for political engagement and involvement of government leaders and Ministries of Finance in preparing health workforce policies; its approaches are mainly addressing technical capacities within the health sector.  So far limited capacity has been built by these organizations to have health workforce policies addressed in relation to national fiscal policies and larger macro-economic policy frameworks.  In general, public health capacity, for instance via health impact assessments, can be strengthened. This can provide evidence based responses to e.g. bilateral or regional Trade Agreements, liberalization of the labor markets, fiscal flexibility for public services, There might be a role for NGOs to be involved in future capacity sharing on this matter, and that can be built forward on current  involvement in health systems strengthening.

Some LMIC countries have recently developed capacity and an approach to develop strong public services. Brazil is a good example in this, and its workforce ratios have improved considerably over the 20 years. The Brazilian public sector has played a crucial role in promoting stability and setting up the conditions for economic and social development. Workforce policies are linked to expansion of the Unified Health System (Sistema Unico de Saúde - SUS). Due to national and state national health conferences, and via a strong HRH observatory, a momentum to build a comprehensive health system has maintained.[15] Thailand has also been able to strengthen its system. Via a multiple of health sector and socio-economic reforms that have led to a more balanced and well distributed and motivated workforce.[16] In Africa, countries like Malawi and Kenya have made some progress in expanding its workforce by implementing emergency programs that, via the use of donor-funding, by-passed fiscal caps and were able to increase its publicly employed health work with more than 20%.  The impact on the longer term remains to be seen, as much donor funding to the countries has stopped over the last years, and we have to observe how these governments invest in the health workforce on the long term.

Conclusion

The last 2 years or so, attention to the health workforce in the global health debate has reduced. This is probably because much attention goes to Universal Health Coverage and its financing mechanisms, also in relation to the post 2015 development framework. In Europe we have turned our attention to our own health service systems that are under severe pressure. Whether in Europe or in LMICs, the availability of a strong workforce remains a prerequisite for a strong universal and qualitative systems. We should keep our attention to health workforce in relation to UHC, as this might become otherwise the bottleneck to attain comprehensive health systems. And what will be the role of health workers in such a system? Will it be merely providing selective diagnosis and treatment, or will they have the autonomous space to address health of people and communities from an integrated and public health approach? The Alma Ata PHC concept envisages the latter, but even in more advanced health systems in Europe, there is more and more the tendency for health workers to work cost-effectively in a more results based financing matter. The orientation of this model to treating diseases rather than promoting health reduces the health worker to merely a production unit. We do not only need health workers, we require professionals in society working on health and wellbeing. The Finnish government provides good examples how this can be done.[17].  

Let me end with a quote by Rick Rowden: “While health advocates are right to criticize that “the IMF blocks health spending,” it is more comprehensive to say that “the IMF blocks the development of domestic industrialization; and without building domestic industries, jobs, and economic diversification over time, you can’t build a tax base for future increased expenditure; and without a growing tax base for future increased public expenditure, you can’t adequately finance a health budget”[18].  We must keep this in mind when building our future health workforce both in Europe and countries elsewhere.  

Dr. Remco van de Pas, Wemos foundation, the Netherlands
remco.van.de.pas@wemos.nl

Contribution to the Jubilee Conference "50 years Medicus Mundi:  Atención Primaria de Salud y Cooperación: ¿una utopía?". Barcelona, 7 June 2013

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[1] Ted Schrecker. Interrogating scarcity: how to think about ‘resource-scarce settings'. Health Policy Plan. 2012  published 16 August 2012. Available at: http://heapol.oxfordjournals.org/content/early/2012/08/16/heapol.czs071.full.pdf+html?etoc

[2] Fukuyama F. The end of history? 1989.The National Interest. Available at: http://www.wesjones.com/eoh.htm

[3]    WHO. World Health Report 2006. Working together for health. Chapter 1. Health workers a global profile. Available at: http://www.who.int/whr/2006/06_chap1_en.pdf

[4]    Lehmann U, Van Damme W, Barten F, Sanders D: Task shifting: the answer to the human resources crisis in Africa?Hum Resour Health 2009, 7:49. Available at: http://www.human-resources-health.com/content/pdf/1478-4491-7-49.pdf

[5]    Wibulpolprasert S, Pengpaiboon P: Integrated strategies to tackle the inequitable distribution of doctors in Thailand: four decades of experience. Human Resources for Health 2003, 1:12. Available at: http://www.human-resources-health.com/content/pdf/1478-4491-1-12.pdf

[6]    Klein N . The Shock doctrine (the rise of disaster capitalism). Knopf Canada. 2007. 

[7]    Center for Global Development. Does the IMF constrain health spending in poor countries?  Report of the working Group on IMF Programs and Health Spending. June 2007. Available at: http://www.cgdev.org/files/14103_file_IMF_report.pdf

[8]    Karanikolos et al, Financial crisis, austerity, and health in Europe. The Lancet - 13 April 2013 ( Vol. 381, Issue 9874, Pages 1323-1331). Available at: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2813%2960102-6/fulltext?_eventId=login

[9]    Ibid 8.

[10]  Henry, JS  The price of offschore revisited. NEW ESTIMATES FOR MISSING GLOBALPRIVATE WEALTH, INCOME, INEQUALITY, AND LOST TAXES. Tax Justice Network. July 2012. Available at: http://www.taxjustice.net/cms/upload/pdf/Price_of_Offshore_Revisited_26072012.pdf

[11]  Global Health Watch 1, An alternative world health report. The global health worker crises. 2005. Available at:     http://www.ghwatch.org/sites/www.ghwatch.org/files/B3.pdf

[12]  Missoni E. Understanding the impact of Global Trade Liberalization on health systems pursuing Universal Health Coverage. Value in Health. 2013. Volume 16, Issue 1, Pages S14-S18 

[13]  WHO & the Global Health Workforce Alliance. The Kampala Declaration and Agenda for Action. 2008. Available at:http://www.who.int/workforcealliance/Kampala%20Declaration%20and%20Agenda%20web%20file.%20FINAL.pdf

[14] WHO. The global code of Practice on the international recruitment of health personnel. Sixty-third World Health Assembly. WHA 63.13. May 2010. Available at: http://www.who.int/hrh/migration/code/code_en.pdf

[15]. Buchan J, Fronteira I, Dussault G,, Continuity and change in human resources policies for health: lessons from Brazil. Human Resources for Health 2011, 9:17. Available at: http://www.human-resources-health.com/content/9/1/17

[16] Ibid 5.

[17] Melkas T. Health in all policies as a priority in Finnish health policy: a case study on national health policy development. Scand J Public Health. 2013 Mar;41(11 Suppl):3-28. Available at : http://sjp.sagepub.com/content/41/11_suppl/3.long

[18] Rick Rowden. Why health advocates must get involved in development economics: the case of the International Monetary Fund. International Journal of Health Services, Volume 40, Number 1, Pages 183–187, 2010. Available at: http://people.ds.cam.ac.uk/ds450/details/rowden_IMFhealth.pdf