Policy brief Rehabilitating the workforce: the key to scaling up MCNCH COPING WITH CRISIS: POLICY RECOMMENDATIONS First are the incentive packages, aimed at improving productivity, de The vicious circle of demotivation, low productivity, and underinvestment ployment and retention of staff (for example performance-linked incen- affects the whole health sector, not only the workforce that provides tives, possibilities for training c mobility, housing benefits or peer care for mothers, newboms and children For countries to move towards pressure mechanisms), and measures to discourage migration or facilitate universal access to MNCH care they must establish and implement com- return of expatriate statt. A second group of measures is aimed at level- prehensive action plans to address the health workforce crisis. These ling the playing field: reinstatement of regulatory oversight mechanisms, plans have to combine action, within the health sector and beyond, realistic recruitment policies-directly, through contracting or through to prevent further harm, expansion of the workforce and immediate other means-and, very important in some countries, putting an end rehabilitative measures, including in terms of remuneration to the payments for ghost workers. Bringing licensing and delegation of authority in line with the reality of the field-for example where regula Prevent further harm ,Well-intended projects, programmes or tions prohibit staff from providing care they are capable of giving-is eforms in the health sector may be contributing to distortions in the another measure that in some circumstances can yield major dividends, health labour market. Such effects must be anticipated through constant as it removes an obstacle to care and at the same time increases job sat- and systematic attention to the implications of such initiatives for the isfaction. SWAp mechanisms, bilateral agreements or the introduction of workforce: all major initiatives require a prior assessment of their poten- codes of conduct can be used to harmonise the human resource policies ial impact, direct and indirect, on the workforce. Anticipating distortions of donor and technical agencies as well as other employers of health per through systematic human resource impact assessments should become sonnel. None of these measures will by themselves be enough to put right a routine part of the preparation of major projects or initiatives in the the consequences of years of crisis, but together they may pave the way health sector, and in particular of major disease control projects. This for bringing productivity and dedication back to the level the population will require improved information systems on human resources so that the expects and to which most health workers aspire. It is particularly policies for which governments opt are based on better intelligence about important for countries to carefully monitor the positive-and the perverse the evolution of the health system effects of these measures, to gradually build up a body of evidence on how to find a way out of the present crisis Prepare the future- planned expansion of the workforce on the basis of a political consensus> Producing sufficient numbers of adequately skilled Confront the remuneration issue For all the long term planning and professionals for the health sector in general, and specifically to scale up short term rehabilitative efforts, without sufficient remuneration and ben- MNCH services, is a long term endeavour. Choices regarding professional efits, and with inadequate working conditions the prospects for recruit- profiles, skills mix and formulas for pre-and in-service training have ing, deploying and retaining the professionals needed for scaling up are consequences that play out years down the road: training more without bleak in many countries. Though the situation may vary considerably from training differently will perpetuate the present problems. Increasing the country to country, many governments have to confront the remuneration upply of human resources for health requires careful planning, manage issue as a matter of urgency ment and institutional development; there is a long lag-time before the st. the volume of funds available for the workforce needs to be benefits become apparent. This makes it all the more necessary to ensure increased substantially, over and above current public expenditure on health a long term and structural commitment to developing the workforce Plan modest efforts will be often be insufficient to attract retain and rede ning and managing the expansion of the HRH workforce is not something ploy quality staff. This has political and macroeconomic implications, and that can be conducted by Ministry of Health technicians alone. It requires cannot be done for MNCH professionals in isolation. It has to be part of the commitment of a broad constituency that stretches well beyond the an overall national strategy for human resources for health, which also Ministry of Health and the Ministry of Education. This is crucial in order to requires a combined effort from domestic and international funding protect the continuity of the scale-up efforts from political fickleness and sources. Second, injecting more funds is only part of the solution.What from the pressure to show immediate results. It is also necessary because is now needed is a clear signal that improvements will be structural without a broad political consensus it is difficult to make the necessary sustained and predictable. This requires the human funding to be improvements to the working environment and the structure of the labour channelled through the core mechanisms and institutions that ensure prog- market for recruiting, deploying and retaining the new stream of quality ress towards universal coverage. Third, there is a need for a strong and professionals effective national leadership, particularly given the distorting influence of the international environment and multiple global initiatives on the labour Take immediate corrective measures to rehabilitate productivity and market in the health sector. morale b It is true that the workforce crisis is so profound that ne piecemeal approach will be able to solve it. Yet, after years of neglect and Make the HRH crisis a matter of national importance b On the eve of decay there are distortions that require immediate attention. Governments a decade that will be focused on human resources for health the human can in actual fact draw on a battery of short term measures to rehabilitate resource crisis is now well recognised internationally. This is important, productivity and morale. None of these measures will by themselves be but it is not enough. The key is to create the political momentum, within enough to put right the consequences of years of crisis. They can, how. each affected country, that puts the workforce crisis on the agenda as a ever, mitigate the most blatant distortions, or, at the very least, create matter of national, and not merely sectoral importance. This is all the more and expand islands of good practice that can serve as role models for the critical since a real rehabilitation of the workforce requires an atmosphere sector. Together they may thus reinstate confidence and a sense of hope, of stability and hope, to give health professionals the confidence they and pave the way for redressing the situation over a period of years eed to work effectively and with dedicatic There is now more and better documentation on the extent of the work- force crisis. On the other hand, evidence is scanty on what works and what does not to help solve it. But there is a variety of measures that may articular contextsPolicy brief Rehabilitating the workforce: the key to scaling up MCNCH COPING WITH CRISIS: POLICY RECOMMENDATIONS The vicious circle of demotivation, low productivity, and underinvestment affects the whole health sector, not only the workforce that provides care for mothers, newborns and children. For countries to move towards universal access to MNCH care they must establish and implement com￾prehensive action plans to address the health workforce crisis. These plans have to combine action, within the health sector and beyond, to prevent further harm, expansion of the workforce, and immediate rehabilitative measures, including in terms of remuneration. Prevent further harm ► Well-intended projects, programmes or reforms in the health sector may be contributing to distortions in the health labour market. Such effects must be anticipated through constant and systematic attention to the implications of such initiatives for the workforce: all major initiatives require a prior assessment of their poten￾tial impact, direct and indirect, on the workforce. Anticipating distortions through systematic human resource impact assessments should become a routine part of the preparation of major projects or initiatives in the health sector, and in particular of major disease control projects. This will require improved information systems on human resources so that the policies for which governments opt are based on better intelligence about the evolution of the health system. Prepare the future - planned expansion of the workforce on the basis of a political consensus ► Producing sufficient numbers of adequately skilled professionals for the health sector in general, and specifically to scale up MNCH services, is a long term endeavour. Choices regarding professional profiles, skills mix and formulas for pre- and in-service training have consequences that play out years down the road: training more without training differently will perpetuate the present problems. Increasing the supply of human resources for health requires careful planning, manage￾ment and institutional development; there is a long lag-time before the benefits become apparent. This makes it all the more necessary to ensure a long term and structural commitment to developing the workforce. Plan￾ning and managing the expansion of the HRH workforce is not something that can be conducted by Ministry of Health technicians alone. It requires the commitment of a broad constituency that stretches well beyond the Ministry of Health and the Ministry of Education. This is crucial in order to protect the continuity of the scale-up efforts from political fickleness and from the pressure to show immediate results. It is also necessary because without a broad political consensus it is difficult to make the necessary improvements to the working environment and the structure of the labour market for recruiting, deploying and retaining the new stream of quality professionals. Take immediate corrective measures to rehabilitate productivity and morale ► It is true that the workforce crisis is so profound that no piecemeal approach will be able to solve it. Yet, after years of neglect and decay there are distortions that require immediate attention. Governments can in actual fact draw on a battery of short term measures to rehabilitate productivity and morale. None of these measures will by themselves be enough to put right the consequences of years of crisis. They can, how￾ever, mitigate the most blatant distortions, or, at the very least, create and expand islands of good practice that can serve as role models for the sector. Together they may thus reinstate confidence and a sense of hope, and pave the way for redressing the situation over a period of years. There is now more and better documentation on the extent of the work￾force crisis. On the other hand, evidence is scanty on what works and what does not to help solve it. But there is a variety of measures that may be of use in particular contexts. First are the incentive packages, aimed at improving productivity, de￾ployment and retention of staff (for example performance-linked incen￾tives, possibilities for training or career mobility, housing benefits or peer pressure mechanisms), and measures to discourage migration or facilitate return of expatriate staff. A second group of measures is aimed at level￾ling the playing field: reinstatement of regulatory oversight mechanisms, realistic recruitment policies – directly, through contracting or through other means – and, very important in some countries, putting an end to the payments for ghost workers. Bringing licensing and delegation of authority in line with the reality of the field – for example where regula￾tions prohibit staff from providing care they are capable of giving – is another measure that in some circumstances can yield major dividends, as it removes an obstacle to care and at the same time increases job sat￾isfaction. SWAp mechanisms, bilateral agreements or the introduction of codes of conduct can be used to harmonise the human resource policies of donor and technical agencies as well as other employers of health per￾sonnel. None of these measures will by themselves be enough to put right the consequences of years of crisis, but together they may pave the way for bringing productivity and dedication back to the level the population expects and to which most health workers aspire. It is particularly important for countries to carefully monitor the positive – and the perverse – effects of these measures, to gradually build up a body of evidence on how to find a way out of the present crisis. Confront the remuneration issue ► For all the long term planning and short term rehabilitative efforts, without sufficient remuneration and ben￾efits, and with inadequate working conditions the prospects for recruit￾ing, deploying and retaining the professionals needed for scaling up are bleak in many countries. Though the situation may vary considerably from country to country, many governments have to confront the remuneration issue as a matter of urgency. First, the volume of funds available for the workforce needs to be increased substantially, over and above current public expenditure on health - modest efforts will be often be insufficient to attract, retain and rede￾ploy quality staff. This has political and macroeconomic implications, and cannot be done for MNCH professionals in isolation. It has to be part of an overall national strategy for human resources for health, which also requires a combined effort from domestic and international funding sources. Second, injecting more funds is only part of the solution. What is now needed is a clear signal that improvements will be structural, sustained and predictable. This requires the human resource funding to be channelled through the core mechanisms and institutions that ensure prog￾ress towards universal coverage. Third, there is a need for a strong and effective national leadership, particularly given the distorting influence of the international environment and multiple global initiatives on the labour market in the health sector. Make the HRH crisis a matter of national importance ► On the eve of a decade that will be focused on human resources for health, the human resource crisis is now well recognised internationally. This is important, but it is not enough. The key is to create the political momentum, within each affected country, that puts the workforce crisis on the agenda as a matter of national, and not merely sectoral importance. This is all the more critical since a real rehabilitation of the workforce requires an atmosphere of stability and hope, to give health professionals the confidence they need to work effectively and with dedication. 2_rehabilitating workforce.indd 3 2005-03-24 18:49:51