1. Human Resources for
Health
Dr. Nilar Tin

2. A Rational approach to Health manpower
planning (1978) Tom Hall
1. A newly expanded regional hospital system, completed at
great cost with a foreign loan on which commercial interests
are paid, stands unused for lack of nursing personnel.
2. Over half of the graduates of a ministry of health six-month
training programme for environmental sanitation personnel
were lost permanently to the health sector owing to failure
by the ministry to create necessary jobs in time.
3. Health authorities in the developing countries lament over
the many physicians who emigrates following graduation,
while at the same time citing with pride the high pass rate of
these graduates in licensing examinations in developed
countries.

3. 4.
Health and political authorities, in their desire to avoid
providing rural communities with “second-class” health care,
oppose the use of non-professional personnel in such
areas, hence ensuring that population will be without health
care at all.
5. The gift by a developed country of a modern university
hospital to a developing country has become a double
liability to the recipient- a major drain on its health budget
and a teaching facility inappropriate to local training needs.
6.
One government agency has funded the development of a
large number of training programmes for medical assistants
(HA), while another in charge of reimbursements for health
services under the social insurance system, has declined to
approve payment for the services of these assistants
working under medical supervision.

4. 7.
In order to cover the payroll of an overstaffed health system,
the budgets for drugs, equipment, and maintenance of
facilities have been cut to the point where the productivity of
staff is severely compromised
8. Unwilling to jeopardize the “quality of care” by expanding its
medical school capacity to meet its national needs, a
country has ended up by relying on large numbers of
immigrant physicians urgently needed in their home
countries and ill-equipped to practise medicine in the host
countries.
9. Over one third of the people in one continent are without
medical care despite a reasonably good overall doctor:
population ratio.
10. (42) new medical schools have opened in one country in 4
years.

5. The scope of Health Manpower Process
Overall aim: To ensure the manpower needed by the health
care delivery system
Health MP Planning
Health MP
Production
Goal
To provide the
framework within
which HMP process
takes place
To provide the
manpower
required
Objective
To specify the no: of To produce x
teams and the
people of y types
composition needed
to improve the level
of health up to a
proposed level
Health MP
Management
To optimize
the use of
HMP
To determine
MP distribution
& productivity
standards,
patterns of
utilization &non
labour inputs

6. The scope of Health Manpower Process
Health MP Planning
Strategy
Health MP
Production
-Regional (sub-national) -Educational
planning and local
planning
programming
-HMP project
formulation
-Aggregation,
reconciliation and
consolidation
-programming
educational
objectives &
teaching
methods
Health MP
Management
Reorganization
-regionalization
-integration of
prevention and
cure
-country health
programming
PHC
-HMP project
management

7. The scope of Health Manpower Process
Health MP
Planning
Activities -Planning and
programming
-Coordination
-Monitoring and
evaluating
implementation
-Research and
development
Health MP
Production
-Recruitment
campaign
Health MP
Management
Establishment and
Implementation of:
-supervision system
-Definition of
-referral system
admission
-continuing education
procedures and
-recruitment &
syllabus
selection procedures
-career development
-Definition of
schemes
teaching methods -deployment of
manpower
-Evaluation of
-staffing patterns
process and
products

8. The scope of Health Manpower Process
Health MP
Planning
Targets
X health teams of
Y composition in
operation by time
T
Health MP
Production
X trained
personnel of Y
type by time T
Health MP
Management
X units of service of
specified quality
delivered to defined
population
-coverage
HRH planning seeks to ensure that:
-the right numbers of HRH are available
-at the right place
-at the right time
-with the requisite skills and motivation
to deliver health care to the population

9. Working together for health 2006

We have to work together to ensure access to a
motivated, skilled, and supported health worker by
every person in every village. (LEE Jong-wook 2005)

WHO Region of America 10% global burden-has 37%
of the world’s health workers spending more than 50%
of world’s health financing (Why?)

Africa Region -24% of burden but only 3% of health
workers, less than 1% of world’s health expenditure
(Why?)

10. Push & Pull Factors

Push Factors



Endogenous
Exogenous
Pull Factors
- low remuneration levels
- work associated risks—TB,HIV/AIDS
- inadequate HR plan with unrealistic workload
- poor infrastructure
- sub optimal conditions of work
- lack of further education and career ladder
- minimal or absent support and supervision
- political insecurity
- crime
- taxation
- aggressive recruitment by recipient countries
- improved quality of life
- study and specialization opportunities
- improved pay

11. Working lifespan strategies
ENTRY:
Preparing the workforce
Planning
Education
Recruitment
WORKFORCE:
Enhancing worker performance
Supervision
Compensation
Systems supports
Lifelong learning
EXIT:
Managing attrition
Migration
Career choice
Health and safety
Retirement
WORFORCE
PERFORMANCE
Availability
Competence
Responsiveness
Productivity

12. Entry-preparing the workforce

Building strong institutions:






For education is essential to secure no: and quality of health workers
required by health system
The world’s 1600 medical schools, 6000 nursing schools, 375 School
of PH…need more schools of PH
Shift of expectations of graduates from “know-all” to “know-how”
Teaching staff…also have to be competent, require training, career
incentives, credible support
Telemedicine and distance education (pooling of resources and kn
mgt)
Assuring educational quality


Institutional accreditation and professional regulation (licensing,
certification and registration)
Too many private schools…benefits vs quality?

13. Workforce Enhancing Performance

Supervision makes a big difference





Fair and reliable compensation




Decent pay arrival on time
Financial incentive
Non-financial incentive-study leave/child care
Critical support systems




Supportive supervision
Clear job description
Feedback on performance
On the job training
Lack in clean water, sanitation, adequate lighting
Vehicles
Drugs, working equipments
Life long learning


Short term training
Team work, sharing solutions

14. Exit: Managing migration and attrition

Managing migration of health workers




Keeping health work as a career of choice for women


Feminization-look into safety, protecting from violence
Ensuring safe working environment



Should be planned migration
Recipient countries should adopt responsible recruitment policy, treat
health workers fairly and consider entering into bilateral agreementsWHO Code of practice in recruiting health workforce
Excessive internal migration can cause urban concentration and rural
neglect
HIV/AIDS-outflow from workforce due to illness, disability and death
Occupational hazards
Retirement planning

Recruit retirees back to work force-improve their living conditions

15. Priority Countries
The World Health Report 2006 identified 57
priority countries that fell below the
threshold of 2.3 doctors, nurses and midwives
for every 1000 people- the minimum number
generally considered necessary to deliver
essential health services
 Africa, Asia, Central Americal, South America,
& Oceania


16. Health Workforce 2008

Health Workforce is defined as a stock of
all people engaged in actions whose
primary intent is to enhance health
CBHV
Public
HWF
Private
NGO
Health care
Provider
H. Management and Support
Workers

17. Health Challenges for SEAR






Emerging infectious diseases: SARS, AI, HIV, TB,
Malaria
Public Health Emergencies: natural disasters
requiring rapid response and disaster preparedness
Chronic non-communicable diseases requiring long
term care
Developments in biotechnology-advanced
diagnostic and curative facilities-require labour
intensive health care services
Rising patients’ expectations of health care delivery
Health workforce shortages

18. Health Workforce (HWF) Challenges

Need for evidence based strategic HWF planning

Comprehensive data regarding HWF distribution, public,
private, community, NGOs, partners

Imbalances in skills, geographic distribution, gender, optimal
skill-mix

Relevance of training: pre-service, in-service training
directed to country health needs.

HWF recruitment, management, working environment,
financing, retention, exit/migration of HWF

International and internal migration of health workforce

19. WHO’s Response to HWF Problems

59th session of the Regional Committee: Dhaka
Declaration: Strengthening Health Workforce
in countries of the SEA Region, 2007

Regional Strategic Plan for HWF development in
the SEA Region

WHO HQ-Regional-Country HWF data base
harmonized with the country data base

Regional guidelines for HWF Strategic Plan

WHO Code of Practice on international
recruitment of HWF (2010 63rd WHA)

20. Global Response to HWF Problems

Global Health workforce Alliance GWHA

2008 The Kampala Declaration and Agenda for
Global Action (1st Global Health Forum in
Uganda)

To strengthen HWF at all levels
To track progress in implementing the strategies
adopted
To have access for all to skilled, motivated and
supported health workers



21. Rationale for Health Workforce Strategic
Planning
1. HWF Shortages
2. Lack of reliable, harmonized data on
HWF
3. Resource Constraints
4. Partnership development
5. Requirements are diverse categories
HWF

23. Health Workforce Imbalances

24. HWF Density in SEAR
(doc,nur,mw,dent,pharm,lab tech only)
Density of Health Work Force in SEAR Countries
SEA Region
Timor Leste
Thailand
Sri Lanka
Nepal
Myanmar
Maldives
Indonesia
India
DPRK
Bhutan
Bangladesh
0
10
20
30
40
50
60
Total Health workers per 10 000 population
70
80
90

25. WHY do we need HWF Strategic Planning?
“Strategic Planning for HWF”

Coordinated: multi factorial, multi-stakeholders
involvement

Systematic: time constraints, resource limitations

National HWF Policy approach

Partnership between national and international
developmental partners

Medium-term or long-term vision to achieve targets

26. The Strategic planning framework
The strategic framework consists of six steps which are:
Health Workforce Situational analysis

Problem Identification & Prioritization

Projection of HWF Needs and Demands

HWF Policy Review and Identification of Strategic Areas

Formulating the Strategic Plan

Monitoring and Evaluation

27. Health Workforce Strategic Planning Framework

28. Six major factors influencing the entry,
sustainability and exit from HWF IN HS






Education and training
HWF Management
HWF Financing
HWF Policy
Partnerships
Leadership

29. 1.Education/Training of HWF

Pre-service education/training; institutional capacity

In-service education and training and capacity building.

Relevance of curricula to address country’s health need

Inclusion of soft skills

Faculty development.

Accreditation system for internal and internal &external
quality assurance mechanism.

Medical and Health professional education research for
innovations in education to address current HWF problems.

30. 2.HWF management capacity

Density and distribution of HWF, with regard to
equitable coverage, gender equity and relevance,
appropriate skill mix

HWF information system, regular updating of HWF
data including private sector and NGOs, health
workforce in numbers, competencies and
distribution

Financing of HWF which consists of salary profile
of different categories of HWF, for different
geographic areas, different sectors, and

Incentive system for manning remote health
centers.

31. 2.HWF management capacity

HWF support for housing, healthcare,
transportation and children’s education and
welfare, working environment supportive for
maximum performance; facilities and equipments,
drugs, supplies and support staff.

Opportunities for promotion, personal and
professional development for HWF.

Data, information and causes for attrition, brain
drain, migration pattern and presence of “ghost
health workers” or absenteeism.

32. 3.HWF policy and regulations

Is there HWF policy reflected in the National Health
Policy of the country?

Work load indicators and staffing needs

Deployment policies, recruitment policies, transfer,
promotion, grievances, incentives including
performance-based incentives, and career
advancement policies.

HWF exit policy: pension and gratuity entitlements have
to be taken into account.

Regulations on ethical conduct, liability and quality
assurance mechanisms for the HWF, both in public and
private sector.

33. 3.HWF policy and regulations

Relationship between HWF and Public Health
standard at different level of health facilities.

Coordination with other related sector/departments.

International code of conduct for recruitment of
health professionals

34. 4. HWF Financing
Macroeconomic profiles:





national health accounts and
national health spending in relation to GDP,
national budget for HRH development,
other sources of funding /spending for HRH

Salary rates of different levels of HRH and other
entitlements

Salary rates compared to bench marks in the
other sectors

35. 4. HWF Financing

Ratio of public to private out of pocket spending
for health

Health spending on non-salary finances

Multiple job holdings may result due to low
salaries.

Moon-lighting in the private sector is one strategy
for HWF in the public sector to survive, however it
can lower the efficiency in the public sector.

Supportive working environment with essential
logistics

36. 5.HWF partnerships

Partnerships with international developmental
partners

Existences of co ordination mechanisms for
international funds to align with national health
priorities and effective scaling up of health workers
training and education.

Partnerships with academic professional bodies for
quality assurance and accreditation such as the
World Federation for Medical Education.

Partnerships with the Global Health Workforce
Alliance and the Asia-Pacific Action Alliance of
Human Resources for Health

37. 5.HWF partnerships
HWF issues relating to international migration
requires policy dialogue with international
organizations like -----




International Labour Organization (ILO),
International Organization on Migration (IOM),
Organization for Economic Co operation and
Development (OECD),
Government to Government negotiations in ethical
recruitment practices, and partnership building
becomes important.
Private-public partnerships not only for scale-up of
disease-specific programs and community-based
health workforce training and education to improve
coverage, but also for training and multi-skilling of
HWF

38. 6. HWF leadership



Leadership development for HWF
planning and management.
Focal point for HWF, National Committee
for HWF development,
Multi-stake holder mechanism is in place
or not.

39. Future Plan for working together

Assist member countries to develop and
implement CSP- HWF

Scaling up of training and education of all
categories of HWF inclusive of CBHW, CBHV.

Innovative educational interventions:
 need based,
 team-based,
 field-based curricula review,
 better co ordination between training and need

Financial support to employ and deploy the
trained workforce

40. Future Plan for working together

HWF management capacity:
 for HWF recruitment and equitable
deployment,
 working conditions conducive for optimal HWF
performance,
 supportive supervision,
 incentive system for retention.

Pooling of Financial resources:
 for long term investment on HWF
development,
 harmonization and alignment of donors to
national priorities.

41. Health System Strengthening by
PHC

HWF is vital for health system
strengthening

CBHW & CBHV are vital to delivery of
health care

HWF development to strengthen
Township health system

42. Projection of HWF Needs and Demands
Supply Forecasting

What numbers of HWF by category are available currently?

What is the geographic distribution of different categories of
HWF?

What is the attrition rate?

Exit from HWF rate and pattern?

Rate of internal and external migration?

Recruitments from other sources? Government –to –
government MOU for recruitment of HWF?

What categories need to be scaled-up training?

43. Projection of HWF Needs and Demands

Supply Forecasting
Is there institutional capacity for scaling up training without
compromising the quality of output?

What are the logistic support required and faculty needed
for scaling up training?

How long will it take to build institutional capacity to meet
the needs?

How much financial support will we need to meet the
supply costs?

How do will fill the supply gap?

Does the current HWF production policy support the
proposed action to meet the supply needs?

44. Projection of HWF Needs and Demands


Demand Forecasting
There are two types of demand, one from the supplier of
health care side (public and private sector) and the other from
patients or clients.
When carrying out a demand analyses there are many other
non-health factors that need consideration.




Economic growth of the country,
growth of the private health sector,
patients’ changing expectations are few factors that will shape up the
countries health service demands.
For example in a country with rapidly expanding economic
growth leading to rapid expansion of the private health sector,


health trade and tourism,
demands for health workers for the private sector
has to be taken into account, so that the public sector will be able to
attract and retain sufficient health personnel.

45. Projection of HWF Needs and Demands
Demand Forecasting

What types of HWF do we need most for the
functioning of the health system according to
findings of situation analysis?

What tools will we use to project the need?

What is the ideal (bench mark) and what is the
current situation?

46. Projection of HWF Needs and Demands
Demand Forecasting

What are the gaps for optimal function of the
health system?

How do we fill the gaps? Scale-up
production/training or scale-up recruitment?

How much financial support will we need to fill
the gap?

Does the current NHP support the proposed
action to meet the demand of the health
system?

47. Projection of HWF Needs and Demands
Methods of HWF demand projection
 There are many methods that have been developed
over time for health workforce demand projection of
which some are basic and some requiring computer
software applications.

The basic methods that have been continuously used
for demand projection by many countries are:
 HWF requirements based on the population ratios
 HWF requirements based on service demands
 HWF requirements based on health system needs
 Work load indicators and staffing needs (WISN)
 “Soft PODD which is a Software Tool for Online
Policy Diagnosis and Dialogue”.